FORM 862 Application for Vocational Rehabilitation Evaluator Please complete the following, sign under penalty of perjury and return with current resume to the: Workers’ Compensation Court ATTENTION: MEDICAL 1915 North Stiles Oklahoma City, OK 73105-4918 ALL INFORMATION SUBMITTED TO THE COURT MAY BE CONSIDERED A PUBLIC RECORD UNDER STATE LAW. Direct all questions concerning disclosures to 405-522-8629. THIS SPACE FOR COURT USE ONLY APPLICANT’S NAME: OFFICE PHONE: NAME OF BUSINESS: OFFICE HOURS: OFFICE ADDRESS: IN WHICH CITY ARE EVALUATIONS PERFORMED: NAME OF CONTACT PERSON TO SCHEDULE APPOINTMENTS: FEE FOR VOCATIONAL EVALUATION: E-MAIL ADDRESS OF APPLICANT: 1. Have you evaluated workers’ compensation claimants for the Court during the past 12 months? YES NO If NO, briefly describe your formal education/training in vocational rehabilitation and provide the Court with a sample vocational evaluation report. ___________________________________________________________________________________________________ 2. __________________________________________________________________________________________________________________ Are you willing to accept Court-imposed limitations on the amount of money you can expect to be paid for depositions, progress reports, evaluation reports? YES NO 3. Will you agree to serve on the Court’s list for an entire one-year period? 4. Are you a Certified Rehabilitation Counselor? YES YES NO 5. Degree(s): ________________________________________________________________________________________________________ 6. List your national and local certifications: _________________________________________________________________________________ NO __________________________________________________________________________________________________________________ 7. Areas of expertise: (Please check all which are applicable) A. Vocational Evaluations B. Job Placement: Please list Hourly Fee charged for this service: ______________________ C. Transferable Skills D. Other (specify) ____________________________________________________________ 8. Do you have errors and omissions and liability insurance? YES 9. Have you ever been convicted of a felony? YES NO NO If YES, please explain: _______________________________________________________________________________________________ __________________________________________________________________________________________________________________ 10. Are you willing to perform vocational evaluations at a location convenient to the claimant’s residence? YES NO If so, what are your estimated fees? ____________________________________________________________________________________ I declare under PENALTY OF PERJURY that the statements contained herein are true and correct to the best of my knowledge and belief. I authorize all associations, organizations and State and Federal agencies to release to the Workers’ Compensation Court all relevant documents and information that may be requested in the investigation of this application. I hereby certify that my certification as a rehabilitation counselor is in good standing. I agree to abide by all applicable Statutes and Court Rules. ______________________________________________________________________ SIGNATURE 08/11 _____________________________ DATE American LegalNet, Inc. www.FormsWorkFlow.com