Vocational Assistance Certification Program Registration of Vocational Assistance Provider Workers' Compensation Division Employment Services Team 350 Winter St. NE P.O. Box 14480 Salem OR 97301-3879 vocassist.oregon@state.or.us Name of provider: Address: City: State: Contact person: Phone: Fax: ZIP: Additional office locations: (Attach additional sheet if necessary.) Address City State Zip Contact person/ phone no. Cert no. Describe the specific vocational services to be provided. Staff roster: (Attach additional sheet if necessary.) Name SSN Cert no. Office location Provider Signature Title Date 440-2814 (3/13/DCBS/WCD/WEB) American LegalNet, Inc. www.FormsWorkFlow.com