Preferred Worker Employment Purchase Agreement (PreEmployment Purchases)
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Preferred Worker Employment Purchase Agreement (PreEmployment Purchases) Form. This is a Oregon form and can be use in Preferred Worker Program Workers Comp.
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Tags: Preferred Worker Employment Purchase Agreement (PreEmployment Purchases), 4123, Oregon Workers Comp, Preferred Worker Program
Preferred Worker
Employment Purchase Agreement
(Pre-employment Purchases)
Workers’ Compensation Division
If you have questions or need further assistance, please contact the Preferred Worker Program in Salem,
503-947-7588; toll-free 800-445-3948; fax 503-947-7581.
Worker information
Name:
Phone:
Complete address:
WCD no.:
(Street/P.O. Box, City,
State, ZIP)
(from front of Preferred Worker card)
In accordance with Oregon Administrative Rules Chapter 436, Division 110, the Workers’
Compensation Division (WCD) and worker agree the following purchases are needed to help the
worker find, accept, or retain employment:
Unit(s)/
amounts
Description of assistance
Unit price
Total price
0.00
0.00
0.00
0.00
0.00
0.00
0.00
Total agreement amount: $
0.00
This agreement is not valid until signed by an authorized representative of WCD.
By my signature, I understand that knowingly misrepresenting information or otherwise falsely obtaining
assistance under this agreement subjects me to sanctions under OAR 436-110-0900; these employment purchases
will become my property, and WCD assumes no liability for injuries or damages caused by any employment
purchase.
Worker signature
Date
WCD USE ONLY
Maximum approved under this agreement
Effective date:
Data entry
$
End date:
Certified true, accurate, correct, and an appropriate expenditure for this program.
Program approval
Date
Fax to: 503-947-7581, or
Send to: Preferred Worker Program, 350 Winter St. NE, P.O. Box 14480, Salem, OR 97309-0405
440-4123 (1/10/DCBS/WCD/WEB)
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