COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. WORKERS’ COMPENSATION :COMMISSION JUDICIAL SUBPOENA Plaintiff(s) -against: REQUEST TO ENTER APPEARANCE OF COUNSEL : This form may NOT be used on behalf of an employer or insurer. : WCC Claim Number: Defendant(s) : ...................................................... Claimant’s Social Security No: Date of Accident: Claimant: THE PEOPLE OF THE STATE OF NEW YORK TO On Behalf of: GREETINGS: Claimant SIF UEF Healthcare Provider WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before ATTORNEY INFORMATION: (Complete in Adobe Reader, Print or Type Only) , the Honorable at the Court located at County of Name of Counsel: in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned Attorney Registration No: as a witness in this action on the part of the date, to testify and give evidence WCC Street Address: City/State/Zip: comply with this subpoena is punishable as a contempt of court and will make you liable to Your failure to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a Telephone: result of your failure to comply. Witness, Honorable Court in County, , one of the Justices of the day of , 20 I hereby certify that on this day of , 20 , a copy of this Request to Enter Appearance of Counsel was mailed to all parties and/or their attorneys. (Attorney must sign above and type name below) Attorney(s) for ___________________________________ Signature Office and P.O. Address WCC Form C24R (Rev. 0828//03) Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: Baltimore, Maryland 21202-1641 10 East Baltimore Street 410-864-5100 Email: info@wcc.state.md.us Web: http://www.wcc.state.md.us American LegalNet, Inc. www.USCourtForms.com