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Vocational Assistance Certification Program Authorization Of Vocational Assistance Provider 2814 - Oregon

Vocational Assistance Certification Program Authorization Of Vocational Assistance Provider Form. This is a Oregon form and can be used in Vocational Rehabilitation Workers Comp .
 Fillable pdf Last Modified 4/14/2010
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Vocational Assistance Certification Program Authorization of Vocational Assistance Provider Workers Compensation Division Compliance Section Vocational Assistance Certification Program 350 Winter St. NE, Room 27, Salem OR 97301-3879 If new application, complete all sections. If renewal, complete Sections 1, 2, 4, and 6 only.  Check categories for which you are requesting Name of provider: authorization: Address: All eligibility determination and vocational City: assistance services State: Return-to-work-specialist services Contact person: (OAR 436-120-0830(3)) Certification no.: Phone: New Renewal (authorization)  Additional office locations: (Attach additional sheet if necessary.) Contact person/ Address City State Zip Cert no. phone no.  Explanation of supervision and training of staff: (New applications only.)  Staff roster: (Attach additional sheet if necessary.) Name SSN Cert no. Office location  State and federal requirements: (List all business licenses and permits held, including federal ID no.)  Check the following: I understand I must Maintain on file with the division a current roster of certified staff, including staff certification numbers. Notify the division within 30 days of any changes in office address, phone number, contact person, or staff. Meet applicable state and federal requirements. Adequately train and supervise certified staff. Provide each certfied staff person with department rules, bulletins, and other information, as prescribed by the director of the Department of Consumer and Business Services. Failure to comply with the above could result in loss of authorization. Signature 440-2814 (12/99/DCBS/WCD/WEB)
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