Workers' Compensation Division Vocational Assistance Certification Program Individual Certification Under OAR 436-120 Check categories for which you are requesting certification based on your training and experience: Renewal Please print Name: (Last) (First) (M.I.) Mailing address: (City) (State) (Home) (ZIP) (Fax) Counselor Intern Phone: (Work) Return-to-work specialist SSN* (See notes at bottom of page.): (E-mail) Renewal: If you are renewing your certification, attach verification of required continuing education credits. Professional certifications: (Attach copy of certification.) If you are attaching your national certification, check the appropriate box and skip to the signature line. CRCC CCMC CDMSC Education and formal training: List enough education to meet the requirements of the category for which you are requesting certification. Include a copy of transcripts. Transcripts will not be returned. Names/locations of colleges or other schools attended Major Dates attended Qtr. Credits earned Sem. Other Year graduated Degree awarded Qualifying work experience: Describe work experience that qualifies you for certification. If your experience is in the area of (1) transferable skills assessment, (2) rehabilitation plan development, (3) employability evaluations, or (4) job analysis, submit a copy of a report you authored. Delete any references to employer/client name or other identifying information. Employer: Address: Supervisor's name: Phone no.: Your title: % of time Total time: (years) (months) Specific duties: From: (month) (year) To: (month) (year) Average hours worked per week: *As part of your application for an initial vocational certification by the Department of Consumer and Business Services (DCBS), you must provide your Social Security number (SSN) to DCBS. This is mandatory. The authority for this requirement is Oregon Laws 1997, Chapter 746, Section 117 (ORS 25.785) and 42 USC § 666(a)(13). Failure to provide your SSN will be a basis for DCBS to refuse to issue the certification you seek. Your SSN will remain on file with DCBS and will be used for child-supportenforcement purposes only, unless you authorize other uses of the number. 440-1880 (3/13/DCBS/WCD/WEB) American LegalNet, Inc. www.FormsWorkFlow.com Employer: Address: Supervisor's name: Phone no.: Your title: Specific duties: % of time Total time: (years) (months) From: (month) (year) To: (month) (year) Average hours worked per week: Employer: Address: Supervisor's name: Phone no.: Your title: Specific duties: % of time Total time: (years) (months) From: (month) (year) To: (month) (year) Average hours worked per week: Signature: Date: 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. For assistance regarding this form, contact the Employment Services Team at 503-947-7816 or 800-452-0288, ext. 7816. Send this completed form, as well as all required documents to: Workers' Compensation Division Resolution Section Employment Services Team 350 Winter St. NE P.O. Box 14480 Salem, Oregon 97309-0405 Keep a copy of this form for your records. 440-1880 (3/13/DCBS/WCD/WEB) American LegalNet, Inc. www.FormsWorkFlow.com