STATE OF CALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONS DIVISION OF WORKERS' COMPENSATION ­ MEDICAL UNIT P.O. Box 71010 Oakland, CA 94612 (510) 286-3700 or (800) 794-6900 REGISTRATION FOR QME COMPETENCY EXAMINATION (DATE) PLEASE COMPLETE THIS REGISTRATION FORM AND RETURN POSTMARKED NO LATER THAN (Date). THE DIVISION OF WORKERS' COMPENSATION (DWC) IS NOT RESPONSIBLE FOR LATE OR LOST APPLICATIONS. PLEASE SEND YOUR REGISTRATION AND APPLICATION FORMS TO: DIVISION OF WORKERS' COMPENSATION - ATTN: EXAM UNIT MAILING ADDRESS: P. O. BOX 71010 OAKLAND, CA 94612 STREET ADDRESS FOR EXPRESS DELIVERY: 1515 CLAY STREET, 18th FLOOR OAKLAND, CA 94612 NAME: LAST FIRST M.I. JR./SR. ADDRESS: STREET CITY STATE ZIP PHONE NUMBER: PHYSICIAN'S LICENSE NUMBER: EXAM DATE & TIME: (Date) FAX: Business Email: (optional) Registration begins at 9:30 a.m. Examination begins at 10:00 a.m. PREFERRED EXAM LOCATION: (TEST SITE WILL BE INDICATED ON YOUR CONFIRMATION LETTER FROM CPS.) Northern California Southern California DO YOU HAVE ANY NEED FOR ACCOMODATIONS DUE TO A DISABILITY OR RELIGIOUS CONFLICT? No AFFIRMATIONS and VERIFICATION Yes (Please see the Special Administration Procedures) I have used all reasonable diligence in preparing and completing this application. I have reviewed this completed application and to the best of my knowledge the information contained herein and in the attached supporting documentation is true, correct and complete. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. I understand that I must keep my license to practice active and that it currently is active. I certify that I am not currently on probation with my licensing board nor on any court-ordered probation. I certify I will notify the DWC of any of the following events: a) change in my license status; b) any past or future conviction related to the conduct of my practice or for any crime of morel turpitude; and c) upon being placed on probation by my licensing board or by any courtordered probation. I certify that all the information and supporting documentation which I have previously submitted to the DWC with earlier QME application(s) is bona fide, true and correct. Executed on: mm/dd/yy at County & State Applicant's Signature QME Form 102 (rev. February 2009) American LegalNet, Inc. www.FormsWorkflow.com REGISTERING FOR SPECIAL ADMINISTRATION PROCEDURES Examinee with a Disabling Condition or Religious Conflict Special administration arrangements can be provided for examinees who, due to a disability or religious conflict, would not be able to take the test under standard conditions. Requests for special arrangements must be made by the REGULAR REGISTRATION DEADLINE. It may not be possible to honor requests for special testing arrangements received after the regular registration deadline. Individuals whose religious convictions prohibit them from taking tests on Saturdays or religious holidays may request a special test administration All of the following must be submitted if special arrangements are needed due to a disability: · a letter from you describing the condition and the specific special arrangements requested; and · a completed registration form. YOUR PROFESSIONAL LICENSE NUMBER AND TELEPHONE NUMBER MUST APPEAR ON ALL CORRESPONDENCE. If you need special facilities (e.g., wheelchair accessible building or restrooms), please notify by letter, Cooperative Personnel Services (CPS) at 241 Lathrop Way, Sacramento, CA 95815. In this case, it is not necessary to submit any medical documentation. Special arrangements for the following conditions can be accommodated at ALL test sites: · special seating (e.g., due to pregnancy) · wheelchair accessible facilities · use of magnifying devices or large-print tests (e.g., for those with visual impairments). Arrangements that require SUBSTANTIAL CHANGES IN TESTING CONDITIONS may be accommodated only at selected test sites. If it is necessary to relocate you to accommodate any other type of request, you will be contacted directly to discuss the arrangement. QME Form 102 (rev. February 2009) American LegalNet, Inc. www.FormsWorkflow.com