Fill and Sign the Oregon Assistance Form

Vocational Assistance Certification Program Individual Certification under OAR 436-120 Please print Requesting certification or renewal of certification for: Vocational rehabilitation counselor Vocational rehabilitation intern Return-to-work specialistName:       (Last) (First) (Middle initial) Mailing address*:             (City) (State) (ZIP) Phone:                   (Work) (Home) (Fax) SSN** (See notes at bottom of page.):             (Email) Provider information: Individuals providing vocational assistance must be on the staff of a registered vocational assistance provider, insurer, or self- insured employer (OAR 436-120-0810). Provider name:       Provider number, if known:       Contact name:       Credentials for certification under OAR 436-120-0810, 0820 (check all that apply) If you are using a professional certification, attach the corresponding certification. If you are using education and formal training to qualify, include a copy of your diploma or transcripts. Number of credits included:       If you are using work experience to qualify, describe the work experience that qualifies you for your certification. Attach additional pages, if necessary. Employer:       Supervisor’s name:       Address:       Phone no.:       Your title:       Specific duties:       % of time       Total time:             (years) (months) From:             (month) (year) To:             (month) (year) Average hours worked per week:       Notes: *Under OAR 436-120-0810, certified individuals must notify the division within 30 days of any changes in address and telephone number. **As part of your application for an initial vocational certification by the Department of Consumer and Business Services, you must provide your Social Security number (SSN). This is mandatory under ORS 25.785. Failure to provide your SSN will be grounds for denial of request. 440-1880 (2/18/DCBS/WCD/WEB) Page 1 of 2 Employer:       Supervisor’s name:       Address:       Phone no.:       Your title:       Specific duties:       % of time       Total time:             (years) (months) From:             (month) (year) To:             (month) (year) Average hours worked per week:       By my signature, I certify that all answers and statements on this application are true and complete to the best of my knowledge. I understand that supervisors may be contacted regarding my job duties. I understand that, should an investigation disclose untruthful or misleading answers, my application may be rejected, my name removed from consideration, or my certification withdrawn. Signature: Date:       For help with this form, contact the Employment Services Team at 503-947-7812 or 800-452-0288 (toll-free). Send this completed form, as well as all required documents to: Workers’ Compensation Division Employment Services Team 350 Winter St. NE P.O. Box 14480 Salem, Oregon 97309-0405 Or, fax to 503-947-7581 440-1880 (2/18/DCBS/WCD/WEB) Keep a copy of this form for your records. Page 2 of 2