Fill and Sign the Vocational Rehabilitation Counselor Resume Samples Form

CC-FORM -862 VOCATIONAL REHABILITATION SERVICES (VRS) REGISTRY FORM Please complete the following, sign under PENALTY OF PERJURY and return with current resume to the: WORKERS’ COMPENSATION COMMISSION ATTENTION: HEALTH SERVICES DIVISION 1915 North S�les Avenue Oklahoma City, OK 73105 ALL INFORMATION SUBMITTED TO THE COMMISSION MAY BE CONSIDERED A PUBLIC RECORD UND ER STATE LAW. Direct all ques�ons concerning disclosures to the Commission’s Health Services Division, (405) 522 -3222 or In -State Toll Free, (855) 291 -3612. APPLICANT’S NAME: OFFICE PHONE: NAME OF BUSINESS: OFFICE HOURS: OFFICE ADDRESS: IN WHICH CITY ARE EVALUATIONS PERFORMED: NAME OF CONTACT PERSON TO SCHEDULE APPOINTMENTS: FEE FOR VOCATIONAL EVALUATION: 1. Professional Creden�als: CRC CVE CDMS Other: _______________ _____________________________________ ______ 2. Do you have any experience or educa�on concerning workers’ compensa�on princi ples or the Oklahoma workers’ compensa�on system? YES NO If yes, please list. (A�ach addi�onal pages i f needed:________________________________ ____________ ___________________________________________________ ___________________________________________________ ________ 3. Have you evaluated workers’ compensa�on claimants during the past 12 months? YES NO If NO, provide the Commission with a sample voca�onal evalua�on report. (A�ach addi�on al pages if needed.) _____________ _____ ___________________________________________________ ___________________________________________________ ________ 4. Are you willing to accept Commission -imposed limita�ons on the amount of money you can expect to be paid for deposi �ons, progr ess reports, evalua�on reports? YES NO 5. Will you agree to serve on the Commission’s list for an en�re one -year period? YES NO 6. Areas of exper�se: (Please check all which are applicable) A. Voca�onal Evalua�ons B. Job Placement: Please list Hourly Fee charged for this service: ______________ _____ C. Transferable Skills D. Other (specify) ____________________________________________________ _____ 7. Do you have errors and omissions and liability insurance? YES NO 8. Have you been convicted of a felony under federal or state law within 7 years be fore the date of this applica�on? YES NO If YES, please explain. (A�ach addi�onal pages if needed.): ________________________________________________________ _____ 9. Are you willing to perform voca�onal evalua�ons at a loca�on convenient to the claim ant’s residence? YES NO If so, what are your es�mated fees? _____________________________ ______________________________________________ I declare under PENALTY OF PERJURY that the statements contained her ein are true and correct to the best of my knowledge and belief. I authorize all associa�ons, organ iza�ons and State and Federal agencies to release to the Okl ahoma Workers’ Compensa�on Commission all relevant documents and in forma�on that may be requested in the inves�ga�on of this applica�on. I hereby cer�fy that my cer��ca�on as a re habilita�on counselor is in good standing. I agree to abide by all applicable statutes and workers’ compensa�on rules and procedures . ___________________________________________________ ___________________________ _______________________ ___________ SIGNATURE DATE Revised 12-18 -14 THIS SPACE FOR COMMISSION USE ONLY E-MAIL ADDRESS OF APPLICANT: