Request For Approval Of Vocational Rehabilitation Training Agreement

COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Plaintiff(s) -against: : Index No. Calendar No. JUDICIAL SUBPOENA REQUEST FOR APPROVAL OF VOCATIONAL REHABILITATION : TRAINING AGREEMENT UNDER RSA 281-A:25 : Defendant(s) EMPLOYEE: : ...................................................... EMPLOYER: INSURANCE CARRIER: DATE OF ACCIDENT: THE PEOPLE OF THE STATE OF NEW YORK TYPE OF INJURY/NATURE AND EXTENT OF DISABILITY: TO GREETINGS: VOCATIONAL GOAL AND RATIONALE: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed DETAILS to THE and give DATES AND COSTS or adjourned date,OF testify PLAN: evidence as a witness in this action on the part of the Carrier responsibilities Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Witness, Honorable Employee responsibilities County, , one of the Justices of the , 20 Court in day of (Attorney must sign above and type name below) Rehabilitation Provider responsibilities Attorney(s) for Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Plaintiff(s) : Index No. Calendar No. PAGE 2 -against: EMPLOYEE: _______________________________ DATE OF INJURY: ___________ : JUDICIAL SUBPOENA BENEFIT PROVISIONS: Please indicate which benefit applies and the duration. : The employee may be eligible forDefendant(s)total, temporary partial, and/or dec rate. temporary : ...................................................... THE PEOPLE OF THE STATE OF NEW YORK TO The medical provisions of the workers' compensation law shall continue as needed. GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court OTHER PROVISIONS: located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed Example: testify copy of OJT agreement, course description, etc. or adjourned date, to Attachand give evidence as a witness in this action on the part of the Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Witness, Honorable Court in County, , one of the Justices of the day of , 20 Employee ____________________________________________ Date______________ (Attorney must sign above and type name below) Rehabilitation Provider __________________________________ Date _____________ Carrier Representative ___________________________________ Date _____________ Attorney(s) for Date Submitted: __________________ Date Approved: __________________ __________________________________ Office and P.O. Address Labor Department Representative Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Plaintiff(s) : Index No. Calendar No. PAGE -against: EMPLOYEE: ______________________________ DATE OF INJURY: ____________ AMENDMENT DATE: _____________________________ : Defendant(s) : ...................................................... : JUDICIAL SUBPOENA THE PEOPLE OF THE STATE OF NEW YORK TO GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Witness, Honorable Court in County, , one of the Justices of the day of , 20 Employee ____________________________________________ Date______________ (Attorney must sign above and type name below) Rehabilitation Provider __________________________________ Date _____________ Carrier Representative ___________________________________ Date ____________ Attorney(s) for Date Submitted: __________________ Date Approved: __________________ __________________________________ Office and P.O. Address Labor Department Representative Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com