Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Request For Approval Of Vocational Rehabilitation Training Agreement Form. This is a New Hampshire form and can be use in Vocational Rehabilitation Workers Comp.
Loading PDF...
Tags: Request For Approval Of Vocational Rehabilitation Training Agreement, New Hampshire Workers Comp, Vocational Rehabilitation
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
Index No.
:
Plaintiff(s)
-against-
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
VOCATIONAL GOAL AND RATIONALE:
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
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.
Court in
Witness, Honorable
Employee responsibilities
County,
day of
, one of the Justices of the
, 20
(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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
Index No.
:
:
Plaintiff(s)
Calendar No.
JUDICIAL SUBPOENA
PAGE 2
-against:
EMPLOYEE: _______________________________ DATE OF INJURY: ___________
:
BENEFIT PROVISIONS:
:
The employee may be eligible forDefendant(s)total, temporary partial, and/or dec rate.
temporary
:
......................................................
Please indicate which benefit applies and the duration.
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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
Index No.
:
Plaintiff(s)
Calendar No.
:
JUDICIAL SUBPOENA
PAGE
-against:
EMPLOYEE: ______________________________ DATE OF INJURY: ____________
:
AMENDMENT DATE: _____________________________
:
Defendant(s)
:
......................................................
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
