Form 33 - North Carolina Industrial Commission, Request That Claim Be Assigned For Hearing Page 2
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2Below is a list of names of all witnesses, including doctors, whose testimony is to be taken by the requesting party. Addresses must be
provided for the doctors listed below.
NAME
ADDRESS
I hereby certify that this case is ready for hearing. When a date of hearing is set, I respectfully request the Commission to
send me signed subpoenas for my witnesses. When I receive these subpoenas, I will serve them pursuant to the instructions on Page 2
of the Industrial Commission Form 36.
(Signature of party requesting hearing) Check one:
Employee,
Employer;
Attorney
(Address: street and number, city, state and zip)
E-mail address:
Telephone number:
Date of notice:
Note: The original of this form must be sent to the Industrial Commission at the address below or by e-mail to
dockets@ic.nc.gov. A copy of the form must be sent to opposing parties.
CERTIFICATE OF SERVICE
I hereby certify that on _________________________, I served a copy of this Form 33 Request for Hearing, together with all
supporting documents, on the following party(ies) by way of
___________________________________________________________.
(U.S. Mail, special delivery mail, e-mail, fax, hand delivery, etc.)
[Note: List name and address of each attorney or party served. Attach a separate sheet if necessary.]
___________________________________________________________________________________________________________
Signature
Printed Name
Date
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