Mercy Pay Dispute

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* 1. Please provide us with your contact information.

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Personal Email Address

Phone Number

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* 2. What was your date of hire?

Date

Date

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* 3. Please provide your date of license

Date

Date

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* 4. What is your job title?

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* 5. Which department/unit do you work in?

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* 6. Employment Status

FT

PT

PRN

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* 7. Please describe the issue(s) you encountered. If at all possible, list dates and amounts.

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* 8. Do you wish to be part of a class action grievance Nurses are filing to ensure payroll justice?

Yes

No

Not sure, please contact me