Form Oc-403.2r - Renewal Application By Employee Of Licensee Under Section 50 3-B Or 50 3-D To Appear Before The Workers' Compensation Board

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State of New York
WORKERS' COMPENSATION BOARD
RENEWAL APPLICATION BY EMPLOYEE OF LICENSEE UNDER SECTION 50 3-b or 50 3-d
TO APPEAR BEFORE THE WORKERS' COMPENSATION BOARD
If additional information is needed, call the Licensing Unit at (1-800)664-2379 or (518)402-1372.
Licensee
License No.
Company/Individual:______________________________________________________________________
Business address:_______________________________________________________________________
The undersigned hereby applies to the Workers' Compensation Board for a renewal of permission to appear
before the Board and WC Law Judges in connection with workers' compensation matters as an employee of
the above-named organization/individual licensed under Section 50 3-b or 50 3-d of the Workers'
Compensation Law.
1. Applicant's Name (first, middle, last):_______________________________________________________
2. Residence Address:____________________________________________________________________
3. Home Telephone No.: (___) ________________
4. List all employment during past three years: (Indicate regular place of doing business. Give present
business first.)
From
To
Employer
Business Address
Salary
5. Business Telephone Number: (___)__________________ Fax Number: (___)_____________________
Since your last application for license under this section, has status changed in following areas:
6. Citizenship:
Yes
No If Yes:
United States of America
Other____________________
q
q
q
q
If naturalized, give date and place of naturalization___________________________________________
If permanent resident alien, give registration no. and date______________________________________
7. Education:
Yes
No
q
q
If Yes, college, university or technical schools attended:
School Name and Address
From
To
Degree
OC-403.2R (2-12)

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