Form Erd-985 - Application Form For Certification By The Subsequent Injury Fund - Montana Department Of Labor And Industry Page 3
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6EDUCATION AND TRAINING
Do You Have A High School Diploma Or Equivalent?
Yes _____ No _____
Do You Have A College Degree? Yes _____ No _____
If Yes, What Year Was Degree Received:_____________
Name Degree(s):
Major _____________________________________________________
Minor _____________________________________________________
Other Certifications, Licenses Or Training Completed (vo-tech, on-the-job training, military,
rehabilitation): ________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Other Skills and Abilities: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Union Membership(s): _________________________________________________________________
______________________________________________________________________________________
EMPLOYMENT STATUS
Are You Employed Now? Yes _____ No _____
If unemployed, is your impairment the cause? Yes _____ No _____
If You Are Currently Employed, Answer The Following:
List the most recent date you returned to work: ______________
Did you return to the same employer: Yes _____ No _____
Did you return to:
Same Job _____
New Job _____ Modified Job _____
If Job Has Been Modified For You, List All Modifications And/Or Accommodations Made By
Your Employer:
______________________________________________________________________________
______________________________________________________________________________
Name Of Current Employer, If Employed: _________________________________________
Address:_______________________________________________________________________
Phone: ________________________________________________________________________
Is Position: Permanent _____ Temporary ______ On-The-Job Training ______
Please submit a copy of your job description if available with this application.
ERD – 985 (REV. 07/05/2000)
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