State of New York
WORKERS' COMPENSATION BOARD
INITIAL 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.
Licensee
License No.
Company/Individual____________________________________________
_____________________
Address_____________________________________________________________________________
The undersigned hereby applies to the Workers' Compensation Board for 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____________________________________ Telephone No.____________________
2. Residence Address___________________________________________________________________
3. Business or Occupation during past 5 years:
From
To
Employer
Address
Salary
4. Social Security No.___________________ Federal Employer ID No. (if any)______________________
(See Privacy Notification on reverse. If you have neither number, explain on reverse.)
5. Citizenship: q United States of America q Other_________________________________________
If naturalized, give date and place of naturalization __________________________________________
If permanent resident alien, give registration no. and date ____________________________________
6. Are you over 18 years of age? q Yes
q No
7. Elementary school :_______________________________________Graduate: q Yes q No
8. High school/equivalent_____________________________________Graduate: q Yes q No
9. College, university or technical schools attended:
School
From
To
Degree
10. Have you ever 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 ___________
__________________________________________________________________________________
11. Have you ever been convicted of a crime? q Yes
q No
If Yes, give details: __________________
__________________________________________________________________________________
Are there any criminal charges now pending against you? q Yes
q No
If Yes, attach statement
giving details.
OC-403.2 (2-12)