LB-0965 (REV 01/18) RDA 10183 Tennessee Bureau of Workers222 Compensation 220 French Landing Drive, I-B Nashville, TN 37243-1002 800-332-2667 FORM C-38 APPLICATION FOR CASE MANAGER REGISTRATION New Registration ($100.00 fee) Renewal of Registration ($50.00 fee) NAME: PHONE EMAIL FAX COMPANY NAME COMPANY STREET ADDRESS CITY STATE ZIP DIRECT SUPERVISOR OR COMPLIANCE OFFICER NAME AND CONTACT INFO: Certification Type Certification # Date Issued Date Expires 1. 2. 3. RN LICENSE (if applicable) # DATE OF EXPIRATION STATE ISSUING LICENSE CIRCLE ONE: Temporary Permanent Please provide a copy of your current RN License, proof of the certification(s) listed above and your payment with this completed form. Please make your check or money order payable to the Tennessee Bureau of Workers222 Compensation. **If this is a renewal, please include proof of Tennessee continuing education hours since your last registration (minimum 4 hours per year). If you self-contract, please provide a list of those companies. By my signature below, I certify that the information provided on this application is true and accurate, to the best of my knowledge. Signature Date American LegalNet, Inc. www.FormsWorkFlow.com