Oregon > Workers Comp > Preferred Worker Program
Preferred Worker Employment Purchase Agreement (PreEmployment Purchases) 4123 - Oregon
| Preferred Worker Employment Purchase Agreement (PreEmployment Purchases) Form. This is a Oregon form and can be used in Preferred Worker Program Workers Comp . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
Preferred Worker Employment Purchase Agreement Workers' Compensation Division (Pre-employment Purchases) If you have questions or need further assistance, please contact the Preferred Worker Program in Salem, 503-947-7588; toll-free 800-445-3948; fax 503-947-7581. Worker information Name: Complete address: (Street/P.O. Box, City, State, ZIP) Phone: WCD no.: (from front of Preferred Worker card) In accordance with Oregon Administrative Rules Chapter 436, Division 110, the Workers' Compensation Division (WCD) and worker agree the following purchases are needed to help the worker find, accept, or retain employment: Description of assistance Unit(s)/ amounts Unit price Total price 0.00 0.00 0.00 0.00 0.00 0.00 0.00 Total agreement amount: $ This agreement is not valid until signed by an authorized representative of WCD. 0.00 By my signature, I understand that knowingly misrepresenting information or otherwise falsely obtaining assistance under this agreement subjects me to sanctions under OAR 436-110-0900; these employment purchases will become my property, and WCD assumes no liability for injuries or damages caused by any employment purchase. Worker signature Date WCD USE ONLY Maximum approved under this agreement Effective date: Data entry $ End date: Certified true, accurate, correct, and an appropriate expenditure for this program. Program approval Date Fax to: 503-947-7581, or Send to: Preferred Worker Program, 350 Winter St. NE, P.O. Box 14480, Salem, OR 97309-0405 440-4123 (1/10/DCBS/WCD/WEB) American LegalNet, Inc. www.FormsWorkFlow.com
|
|||||||
