COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. : APPLICATION FOR EVALUATION JUDICIAL SUBPOENA Plaintiff(s) EMPLOYMENT REHABILITATION SERVICES -against- : Employee: _________________________ Employer: : __________________________ Mailing Address: ___________________ Mailing Address: _____________________ : __________________________________ ____________________________________ Defendant(s) : ...................................................... Phone Number: ____________________ Phone Number: ______________________ Date(s) of Injury: ___________________ THE PEOPLE OF THE STATE OF NEW YORK TO WCB File #: _______________________ Insurer: ____________________________ Mailing Address: _____________________ ____________________________________ Adjuster Name/Phone #: _______________ GREETINGS: Are weekly benefits being paid, either totally or partially? Yes _____ No _____ WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at Yes Court Is a petition pending to remedy discrimination? the _____ No _____; County ofpetition pending to seek located at Is a reinstatement? Yes _____ No _____ 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 ************************************************************************ Application is hereby made to the Workers' Compensation Board pursuant to Title 339A, Subsection 217(1) for anwith this subpoena is punishable asand kind of service, treatment make you liable to Your failure to comply evaluation to address the need for a contempt of court and will or the party on whose behalf this subpoenato return the for a maximum penalty of $50 and all damages sustained as a training necessary and appropriate was issued employee to suitable employment. result of your failure to comply. Dated: ________________________ Witness, Honorable Court in County, day of Filing Instructions: ___________________________________ the , one of the Justices of Requesting Party's Signature , 20 (1) Mail original to: Workers' Compensation Board Office of Med/Rehab Services 27 State House Station (Attorney must sign above and type name below) Augusta, Maine 04333-0027 (2) Mail copies to: Insurer Attorney(s) for Employer or Employee * A letter from the requesting party with the above information is likewise adequate and acceptable. Office and P.O. Address ** Any unrepresented employee may be entitled to the services of an advocate. ** Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com