Private Vocational Rehabilitation Specialist Certification Application SEND COMPLETED FORM TO: DO NOT WRITE IN THIS SPACE PROVIDER NO:____________________ Department of Workforce Development Worker's Compensation Division 201 E. Washington Ave., Rm. C100 P.O. Box 7901 Madison, WI 53707-7901 Telephone: (608) 266-1340 Fax: (608) 267-0394 http://dwd.wisconsin.gov/wc/ e-mail: DWDDWC@dwd.wisconsin.gov ______________________________________________________________________________________________________ Important Note: All persons who provide private-sector vocational rehabilitation services under the State of Wisconsin's Worker's Compensation Act must be certified by the Worker's Compensation Division prior to providing services to injured workers. Failure to complete and submit this form for approval may result in non-payment for rehabilitation services provided to injured workers. Changes in qualification status must be reported immediately to the Worker's Compensation Division. Please Print or Type Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1)(m)]. I. PERSONAL DATA Applicant Name (Last, First, MI) Telephone Number E-Mail Address ( ) ( ) Applicant Business Mailing Address (number, street, city, state and zip code) Employer Telephone Number ) Fax Number ( ) ( Employer Mailing Address (number, street, city, state and zip code) II. QUALIFICATIONS To be certified by the Worker's Compensation Division, you must have a current CRC, CDMS, CVE, State of Wisconsin Professional Counselor license, or comparable qualifications. Attach a copy of your certification. Certification held: CRC CDMS CVE WI Professional Counselor License If you do not have any of the listed certifications, you must submit comparable qualifications with this application. Also, list 3 professional references below: (1) _________________________ _______________________________________ Name Position (______)___________________ Telephone No. (2) _________________________ _______________________________________ Name Position (______)___________________ Telephone No. (3) _________________________ _______________________________________ Name Position (______)___________________ Telephone No. (Over) WKC-10042 (R. 11/2009) American LegalNet, Inc. www.FormsWorkFlow.com General Academic Qualifications Earned Degree Major Area Date Awarded Institution III. EXPERIENCE IN VOCATIONAL REHABILITATION EMPLOYMENT Employment Data (Current job first. List recent positions involving rehabilitation responsibilities.) PLEASE DO NOT SEND RESUME. Employer Name Your Occupation Employer Name Your Occupation Employer Name Your Occupation Location From Location From Location From To To To As a certified specialist, you will provide WC claimants with a full range of re-employment services. Please describe your training and experience in analyzing transferable skills, testing, job placement and retraining plan development. __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Identify up to 6 Wisconsin cities where you will provide services: ______________________________________________ __________________________________________________________________________________________________ Which Wisconsin counties do these cities represent: ________________________________________________________ __________________________________________________________________________________________________ IV. APPLICANT AFFIRMATION AND SIGNATURE: I request certification by the State of Wisconsin Worker's Compensation Division as a private Vocational Rehabilitation Specialist. The information I have provided above is correct and true to the best of my knowledge. I am now available to provide the necessary services injured workers may need to return to work. Applicant Signature: _________________________________________ Date Signed:_____________________ American LegalNet, Inc. www.FormsWorkFlow.com