Form Oc-403.2 - Initial Application By Employee Of Licensee Page 2

Download a blank fillable Form Oc-403.2 - Initial Application By Employee Of Licensee in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Oc-403.2 - Initial Application By Employee Of Licensee with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

In the event I terminate my employment with this licensee, I shall immediately relinquish the identification

card issued to me by the Licensing Unit, 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 obtain disclosure of any information required to

obtain verification of any statement made in this application.

____________________________________________

Signature of Authorized Employee

Sworn to before me this

________day of ______________20 ____

__________________________________

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

Date

application Form OC-403.1

PRIVACY NOTIFICATION

The authority to request personal information from you, including identifying numbers such as Federal Social Security

and Federal Employer Identification Numbers, and the authority to maintain such information, is found in Section 5 of

the Tax Law. Disclosure of this information by you is mandatory. The principal purpose for which this information is

collected is to enable the Department of Taxation and Finance to identify individuals, businesses and others who have

been delinquent in filing tax returns or may have understated their tax liabilities and to generally identify persons

affected by the taxes administered by the Commissioner of Taxation and Finance. The information will be used for tax

administration purposes and for any other purpose authorized by the Tax Law or the Workers' Compensation Law.

The information collected will be held by the Licensing Unit,Workers' Compensation Board. All inquiries regarding

such records should be addressed to the Privacy Compliance Officer, Office of the General Counsel, Workers'

Compensation Board, 328 State Street, Schenectady, NY 12305. Phone: (518) 486-9564.

------------------------------------------------------------------------------------------------------------------------------------------------------------

If you have neither a Social Security Number or Federal Employer Identification Number, please provide an

explanation in the space below: (see Question 4 on front.)

OC-403.2 Reverse (2-12)

Signature of Applicant