Minnesota > Workers Comp
Application For Renewal Of Qualified Rehabilitation Consultant-Consultant Intern Registration R-25 - Minnesota
| Application For Renewal Of Qualified Rehabilitation Consultant-Consultant Intern Registration Form. This is a Minnesota form and can be used in Workers Comp . |
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Minnesota Department of Labor and Industry Financial Services 443 Lafayette Road North St. Paul, MN 55155 (651) 284-5459 or 1-800-342-5354 (DIAL DLI) www.dli.mn.gov R-25 Application for Renewal of: (check one) Qualified Rehabilitation Consultant Registration Qualified Rehabilitation Consultant Intern Registration Please PRINT or TYPE QRC NAME ADDRESS (residence) CITY QRC NUMBER TELEPHONE NUMBER EMPLOYER TELEPHONE NUMBER BUSINESS ADDRESS (Your mailing address) STATE FIRM NUMBER ZIP CODE CITY QRC EXPIRATION DATE STATE ZIP CODE CRC CDMS CRRN OTR Number (if applicable) Attach a copy of your certificate. Enclose a check or money order for $110.00 payable to the Commissioner of the Department of Labor and Industry. (This includes the 10% surcharge pursuant to 2009 Laws, Chapter 101, Article 2, Section 59.) Send all application documents and fees to the Department's Financial Services Section at the above address. CONTINUING EDUCATION DOCUMENTATION OF 20 CONTACT HOURS PER YEAR IS REQUIRED IF A QRC INTERN DOES NOT HAVE CERTIFICATION. (MINN. RULES 5220.1500, SUBP. 3a) COURSE TITLE SPONSOR DATE HOURS MN R-25 (3/12) over American LegalNet, Inc. www.FormsWorkFlow.com Please list any information which was on the original application for registration that we have not received which has changed or is no longer valid. (FOR QUALIFIED REHABILITATION CONSULTANT (QRC) INTERNS ONLY) I request registration renewal and continuing status as a QRC intern. Explain: I have obtained certification as a (check one or more) CRC CDMS CRRN and request registration renewal and approval by the Department of completion of internship. (Minn. Rules 5220.1400, subp. 4) Explain: I authorize the Workers' Compensation Division, Department of Labor and Industry, to make any appropriate investigation of the application and supporting documents. I understand that any omission or misrepresentation may result in rejection or revocation of registration. SUBJECT TO APPROVAL OF THIS APPLICATION I AGREE TO NOTIFY THE DEPARTMENT OF LABOR AND INDUSTRY (651-284-5036) OF ANY CHANGE IN MY EMPLOYMENT STATUS. Given a change in my employment status I will accept responsibility to notify all parties to the cases on which I am the assigned QRC as to whom the reassignment will be made, subject to approval of the Commissioner of Labor and Industry. I hereby agree to be bound by all statutes, rules and orders, and realize that violations may result in revocation of registration. I CERTIFY THAT I AM A FULL-TIME RESIDENT OF MINNESOTA, or I live no more than 100 miles by road from the Minnesota border. (Minn. Rules 5220.1400, subp. 5) APPLICANT SIGNATURE QRC SUPERVISOR SIGNATURE (if applicant is a QRC Intern) DATE DATE This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5459 or 1-800-342-5354/Voice or TDD (651) 297-4198. American LegalNet, Inc. www.FormsWorkFlow.com
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