STATE OF NEW YORK WORKERS' COMPENSATION BOARD INITIAL APPLICATION TO TAKE LICENSE REPRESENTATIVE EXAM TO APPEAR ON BEHALF OF CLAIMANTS (SECTION 24-A OF THE WORKERS' COMPENSATION LAW), OR TO APPEAR ON BEHALF OF OR REPRESENT CARRIERS AND/OR SELF INSURERS [SECTION 50 (3-b/d) OF THE WORKERS' COMPENSATION LAW] APPLICATION IS MADE UNDER (CHECK ONE): " Section 24-a with fee " Section 24-a without fee " Section 50 (3-b) " Section 50 (3-d) Note: Applicants failure to disclose fully and accurately any fact or information called for by any question may result in the denial of the application for a license, or if the license has been issued prior to the discovery thereof, the license may be revoked. 1. Name (first, middle, last) Have you ever been known by any other name? If "Yes," state other name 2. Home Address (if less than 3 years at this address also list previous addresses) Street, City, State From To " Yes " No Home Telephone Number Telephone Number During Normal Business Hours 3. Social Security Number 4. Citizenship: " United States of America " Other If naturalized, give date and place of naturalization If permanent resident alien, give registration number and date OC-409 (2-12) Page 1 American LegalNet, Inc. www.FormsWorkFlow.com 5. Are you over 18 years of age? " Yes " No 6. a. Have you any other license, certificate, or authorization to practice a trade or profession? " Yes " No b. Have you been admitted to the Bar as an attorney (or its equivalent) in any state, territory, or dependency of the United States or any foreign country? " Yes " No c. If you answered "Yes" to either a or b above, give details: 7. a. Have you ever had a license, certificate, or other authorization to practice a trade or profession revoked, suspended, or subject to other disciplinary action? " Yes " No b. Have you ever been disbarred, or has your license to practice law been revoked or suspended? " Yes " No c. If you have answered "Yes" to either a or b, attach a statement giving all details in reference to such disbarment, revocation and/or suspension. " Yes " No 8. Have you ever been convicted of a crime? If "Yes," give details: Are there any criminal charges now pending against you? If "Yes," give details: " Yes " No 9. Name five character references, in the following fields, who have known you for at least five years. (Name only persons who have had a reasonable opportunity to form an opinion of your character, competence, and integrity during the period of acquaintance indicated.) Field Business or Profession Social Family Life & Neighborhood Name Address No. of Yrs. OC-409 (2-12) Page 1 American LegalNet, Inc. www.FormsWorkFlow.com