Form Erd-985 - Application Form For Certification By The Subsequent Injury Fund - Montana Department Of Labor And Industry Page 4

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If You Are Not Currently Employed, Answer The Following:
Are You Currently Applying For A Job?
Yes _____
No _____
Name(s) And Address(es) Of Prospective Employers:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_____________________________________________________________
Type(s) Of Job(s) Applied For:
_______________________________________________________________________________________
_______________________________________________________________________________________
List Job Applications Made In The Past Twelve (12) Months. (Use additional pages if necessary)
Date
Type
Name Of
City
Denied
If Denied
Applied
Of Job
Employer
Yes
No
Reason Given
___________
_______________ ___________________
___________
___
___
__________________
___________
_______________ ___________________
___________
___
___
__________________
___________
_______________ ___________________
___________
___
___
__________________
___________
_______________ __________________
___________
___
___
__________________
EMPLOYMENT HISTORY
LIST YOUR LAST 5-10 YEARS OF EMPLOYMENT HISTORY. THE APPLICATION WILL NOT BE ACCEPTED
WITHOUT THIS INFORMATION. PLEASE PROVIDE JOB TITLES WHERE INDICATED.
Dates
Specific
Name
City
From
To
Job Title
Of Employer
_______
________
_____________________________
__________________________
_________________
_______
________
_____________________________
__________________________
_________________
_______
________
_____________________________
__________________________
_________________
_______
________
_____________________________
__________________________
_________________
_______
________
_____________________________
_________________________
_________________
_______
________
_____________________________
_________________________
_________________
_______
________
_____________________________
_________________________
_________________
ERD – 985 (REV. 07/05/2000)

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