Minnesota Department of Labor and Industry Financial Services 443 Lafayette Road N. St. Paul, MN 55155 (651) 284-5083 or 1-800-342-5354 www.dli.mn.gov R-25 Qualified Rehabilitation Consultant Application (check one) Initial registration Renewal Reinstatement Print in ink or type Applicant's name Telephone number Employer Employer's address City Work email address Telephone number Home address (where certified mail can be delivered) Public mailing address (if different from home address) City QRC number State ZIP code State ZIP code QRC expiration date Firm number Applicant's Minnesota tax ID number (if applicable) Applicant's Social Security number Professional license, certification, registration (check all that apply) Attach a current copy of each license, certificate or registration. CRC CDMS CRRN OTR FOR REINSTATEMENT APPLICATIONS ONLY If you are applying for reinstatement of registration, you must provide verification of all of the following (Minnesota Rules 5220.1500, subp. 4): A. current certification as required by Minn. Rules 5220.1400; B. attendance at the most recent update session or a recording of that session; C. documentation of continuing education requirements as provided by Minn. Rules 5220.1500, subp. 3a; D. payment of any applicable late fees if the applicant failed to notify the commissioner that registration renewal was not being sought; and E. if the applicant has been on inactive status or has failed to renew registration for more than two years, the applicant must also complete an orientation training session before acceptance is final. Payment information: Enclose a check or money order for $100 payable to the "Minnesota Department of Labor and Industry". Send all application documents and fees to the department's Financial Services unit at the above address. MN R-25 (07/2015) American LegalNet, Inc. www.FormsWorkFlow.com I authorize the Workers' Compensation Division, Department of Labor and Industry, to make any appropriate investigation of the application and supporting documents. I understand that any omission or misrepresentation may result in rejection of this application or denial of registration. I agree to be bound by all statutes, rules and orders as established by the commissioner, and realize that violations may result in the denial or revocation of registration. I understand that Minn. Rules 5220.1250 prohibits any ownership or financial relationship of any kind between any registered rehabilitation vendor and qualified rehabilitation consultant firm, qualified rehabilitation consultant or qualified rehabilitation consultant intern. I agree to notify the department immediately of any change in my employment status (Minn. Rules 5220.1400, subp. 5). If there is a change in my employment status, I will notify all parties to the cases on which I am the assigned QRC as to whom the reassignment will be made (Minn. Rules 5220.1801, subp. 9K(2)). I certify that I am a full-time resident of Minnesota or I live no more than 100 miles by road from the Minnesota border (Minn. Rules 5220.1400, subp. 5). Notice: The information you as an individual provide in this application will be used by Department of Labor and Industry (department) staff members who require the information to determine if you meet the department's registration/renewal requirements. Minnesota Statutes § 270C.72, subd. 4, requires you to provide your Social Security number and Minnesota tax identification number on this application. The other information is being requested for purposes of processing your application. With the exception of your Social Security number and Minnesota tax identification number, you are not legally required to supply the data requested on this application. However, failure to provide the requested information may delay the processing of your application or result in the denial of the same. The application data will be made part of the department's file for your registration/renewal. Except for your name and the address you designated to receive correspondence from the department, the information you provide on this application is private data while the application is pending. Once you are registered, the application data may become public except for your Social Security number and Minnesota tax identification number. However, disclosure of private or nonpublic information to others may occur as authorized or required by law, including but not limited to the Attorney General's Office, the Department of Revenue, the Office of Administrative Hearings, upon court order, and/or for the purpose of verification, state investigations and statistics. Applicant signature Date This form is located at www.dli.mn.gov/WC/Wcforms.asp. The form can be made available in different formats, such as large print, Braille or audio. To request, call (651) 284-5032 or 1-800-342-5354. MN R-25 (07/2015) American LegalNet, Inc. www.FormsWorkFlow.com