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 Page 2

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8. Have you been disbarred or had revoked for cause any license, certificate, permit or any other authorization
to practice in any trade or profession?
q
Yes
q
No If Yes, give details:_______________________
___________________________________________________________________________________
___________________________________________________________________________________
q No
9. Have you been convicted of a crime?
q
Yes
If Yes, state when and give details:_____________
___________________________________________________________________________________
___________________________________________________________________________________
10. Are there any criminal charges now pending against you?
q
Yes
q
No If yes, give details:_________
___________________________________________________________________________________
___________________________________________________________________________________
11. Approximately how many claims have you handled before the Workers' Compensation Board (including
WC Law Judge and Board Parts) during the last completed calendar year? _______________________
In the event I terminate my employment with this licensee, I shall immediately relinquish the identification card
issued to me by the Secretary, Workers' Compensation Board.
VERIFICATION
State of New York
)
ss:
County of______________________)
______________________________________________, being duly sworn, deposes and says that I am the
applicant; that I have duly read and signed the foregoing application; that all the matters contained herein are
true, excepting as to such matters therein stated to be alleged on information and belief and those matters I
believe to be true. In addition, I hereby authorize duly designated employees of the Workers' Compensation
Board to make inquiry into and to obtain the release and disclosure of any information, document or record
required to obtain verification of any statement made in this application.
Signature of Authorized Employee
Sworn to before me this
____________day of_______________________
NOTARY'S STAMP
Notary Public
I hereby certify that the above-named applicant is an employee of _________________________________,
which organization/individual has applied or will apply for a license to represent self-insured employers under
Section 50 3-b or 50 3-d of the Workers' Compensation Law.
Signature of Qualifying Officer of Employer who signed application Form C-403.1R
Date
OC-403.2R (2-12) Reverse

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