Preferred Worker Registration {SFN 53235}

PREFERRED WORKER REGISTRATION RETURN TO WORK DIVISION SFN 53235 (08/2014) 1600 EAST CENTURY AVENUE, SUITE 1 PO BOX 5585 BISMARCK ND 58506-5585 TELEPHONE 1-800-777-5033 Toll Free Fax 1-888-786-8695 TTY (hearing impaired) 1-800-366-6888 Fraud and Safety Hotline 1-800-243-3331 www.WorkforceSafety.com Preferred Worker's Name Address Phone Number Claim Number City Are you currently employed? Yes No State Zip Code Date Available for Hire (if known) The Preferred Worker Registration contains recommendations and expectations of Preferred Workers during their work search and during their employment. PREFERRED WORKER EXPECTATIONS If eligible the Preferred Worker: Agrees to use the Work Search Allowance appropriately ($250.00 to be used for appropriate interview clothing, uniforms, travel expenses, or other items deemed necessary for work search). PREFERRED WORKER RECOMMENDATIONS In order to be successful in your work search, experts recommend the following: Register at nearest Job Service and maintain weekly contact. Training in job seeking skills (see web site for WSI-sponsored workshops). Be available for full-time work search, 6-8 hours per day, 5 days per week or according to level of release. Five to ten applications/resumes submitted weekly, as possible. Make 10-15 employer contacts per week for the purpose of seeking employment in targets and/or informational interviews. Two interviews weekly, as possible. Immediate follow-up on job leads. Review of weekend want ads. Keep legible daily log of activities (documentation should include employer contacts: names, dates, and results). Keep WSI apprised of any services received from other agencies. ONCE EMPLOYED The Preferred Worker: Shall abide by the terms of the employer's business practices, policies, and agreements generally affecting all other employees of the employer. Shall perform within restrictions as outlined by the medical provider. Shall notify WSI if the employment ends prior to the exemption period end date. Shall notify WSI if an injury is sustained within the exemption period. PREFERRED WORKER'S SIGNATURE Preferred Worker's Signature Date PROGRAM APPROVAL (WSI use only) Authorized Representative Status Approved Date Denied Pending American LegalNet, Inc. www.FormsWorkFlow.com