Oklahoma > Workers Comp

Application For Vocational Rehabilitation Evaluator CC-Form-862 - Oklahoma

Application For Vocational Rehabilitation Evaluator Form. This is a Oklahoma form and can be used in Workers Comp .
 Fillable pdf Last Modified 2/25/2014
Get this form for FREE as a print-only pdf

CC-FORM-862 VOCATIONAL REHABILITATION SERVICES (VRS) REGISTRY FORM WORKERS' COMPENSATION COMMISSION ATTENTION: HEALTH SERVICES DIVISION N S A Ok a ma Ci y, OK 73 0 Please complete the following, sign under PENALTY OF PERJURY and return with current resume to the: ALL INFORMATION S BMITTED TO THE COMMISSION MAY BE CONSIDERED A P BLIC RECORD NDER STATE LAW Di i g di Ha S i Di i i APPLICANT'S NAME: a OFFICE PHONE: THIS SPACE FOR COMMISSION USE ONLY NAME OF BUSINESS: OFFICE HOURS: OFFICE ADDRESS: IN WHICH CITY ARE EVALUATIONS PERFORMED: NAME OF CONTACT PERSON TO SCHEDULE APPOINTMENTS: FEE FOR VOCATIONAL EVALUATION: E-MAIL ADDRESS OF APPLICANT: 1. 2. Professional Creden als: CRC CVE CDMS Other: Do ou ha e an e perience or educa on concerning wor ers' compensa on principles or the O lahoma wor ers' compensa on s stem YES NO If es, please list. A ach addi onal pages if needed: 3. Ha e ou e aluated wor ers' compensa on claimants during the past 12 months YES NO If NO, pro ide the Commission with a sample oca onal e alua on report. A ach addi onal pages if needed. 4. Are ou willing to accept Commission-imposed limita ons on the amount of mone reports, e alua on reports YES NO YES ou can e pect to e paid for deposi ons, progress 5. 6. Will ou agree to ser e on the Commission's list for an en re one- ear period Areas of e per se: Please chec all which are applica le A. Voca onal E alua ons C. Transfera le S ills NO B. Jo Placement: Please list Hourl Fee charged for this ser ice: D. Other specif NO NO 7. 8. Do ou ha e errors and omissions and lia ilit insurance YES Ha e ou een con icted of a felon under federal or state law within 7 ears efore the date of this applica on YES If YES, please e plain. A ach addi onal pages if needed. : 9. Are ou willing to perform oca onal e alua ons at a loca on con enient to the claimant's residence YES If so, what are our es mated fees NO Id a d PENALTY OF PERJ k dg a d b i f I a ia W k 'C m a C mmi i i a ia I by fy a a a i ab a ad k' RY a am ai d ia ad a ia , ga i a a d S a a d F d a ag i a a ad m a d i f ma a may b di i my a aa abi i a i i g d a di g I ag m a ad d b f my Ok a ma ga f abid by SIGNAT RE DATE C a d 2- - 4 American LegalNet, Inc. www.FormsWorkFlow.com
Link/Embed this Document

Popular Searches

  1. dismissal
  2. writ of execution
  4. civil cover sheet
  5. Declaration
  6. financial affidavit
  7. request for dismissal
  8. satisfaction of judgment
  9. notice of motion
  10. interrogatories

Bookmark and Share