Injured Workers Record Of Job Search Contacts {BWC-2960}

<document>COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.INJUREDWORKERSBetter Workers' CompensationCalendar No.Built with you in mind.RECORDOFJOBSEARCHCONTACTS INSTRUCTIONS: Please print or type. Make sure to enter 4 digits for the year in all date fields. Injuredworker:returncompletedformtoyourCaseManager. Casemanager:follow the distribution list on the reverse side.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)Injured workers nameClaim number1Method of contactJob titleFull name of person contactedFace-to-facePhoneJob applied forEmployer nameEmployer phone number()StateStreet addressCity9-digit ZIP Code Date of contact. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Follow-up dateNumber of miles traveledEmployer responseYesNoPossible2Job titleMethod of contactFull name of person contactedTHE PEOPLE OF THE STATE OF NEW YORK TOFace-to-facePhoneJob applied forEmployer nameEmployer phone number()StateStreet addressCity9-digit ZIP Code Date of contactFollow-up dateNumber of miles traveledEmployer responseYesNoPossible3GREETINGS:Job titleMethod of contactFull name of person contactedFace-to-facePhoneEmployer nameEmployer phone numberJob applied forWE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable()StateStreet addressCity9-digit ZIP Code Date of contact,located at County ofFollow-up dateNumber of miles traveledEmployer responseYesNoPossibleo'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in room4Method of contactJob titleFull name of person contactedFace-to-facePhoneJob applied forEmployer nameEmployer phone number)(StateStreet addressCity9-digit ZIP Code Date of contactYour failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.Follow-up dateNumber of miles traveledEmployer responseYesNoPossible5Date of contactMethod of contactJob titleFull name of person contactedFace-to-facePhone, one of the Justices of theJob applied forEmployer nameEmployer phone numberCourt in Witness, Honorableday of, 20 County,)(StateStreet addressCity9-digit ZIP CodeNumber of miles traveledFollow-up dateEmployer responseYesNoPossible(Attorney must sign above and type name below)6Date of contactMethod of contactJob titleFull name of person contactedFace-to-facePhoneJob applied forEmployer nameEmployer phone number)(Attorney(s) forStateStreet address9-digit ZIP CodeCityNumber of miles traveledFollow-up dateEmployer responseYesPossibleNo7Date of contactMethod of contactJob titleFull name of person contactedOffice and P.O. AddressPhoneFace-to-faceJob applied forEmployer nameEmployer phone number)(StateStreet address9-digit ZIP CodeCityTelephone No.: Facsimile No.: E-Mail Address:Number of miles traveledFollow-up dateEmployer responseYesPossibleNoMobile Tel. No.:BWC-2960 (Rev. 11/13/01) RH-10American LegalNet, Inc. www.USCourtForms.comCOURT COUNTY OF8. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Job titleFull name of person contacted:::::::PhoneIndex No.Job applied forEmployer nameEmployer phone number()StateStreet addressCalendar No.City9-digit ZIP Code Date of contactFollow-up dateNumber of miles traveled Method of contact Face-to-faceEmployer responseYesNoPossibleJUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)9Method of contactJob titleFull name of person contactedFace-to-facePhoneJob applied forEmployer nameEmployer phone number()StateStreet addressCity9-digit ZIP Code Date of contactFollow-up dateNumber of miles traveledEmployer responseYesNoPossible10. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Method of contactJob titleFull name of person contactedFace-to-facePhoneJob applied forEmployer nameEmployer phone number()StateStreet addressCity9-digit ZIP Code Date of contactTHE PEOPLE OF THE STATE OF NEW YORK TOFollow-up dateNumber of miles traveledEmployer responseYesNoPossible11Method of contactJob titleFull name of person contactedFace-to-facePhoneJob applied forEmployer nameEmployer phone number()StateStreet addressCity9-digit ZIP Code Date of contactGREETINGS:Follow-up dateNumber of miles traveledEmployer responseYesNoPossibleWE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable12,Method of contactJob titleFull name of person contactedlocated at County ofFace-to-facePhoneJob applied forEmployer nameEmployer phone numbero'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in room)(StateStreet addressCity9-digit ZIP Code Date of contactFollow-up dateNumber of miles traveledEmployer responseYesNoPossible13Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.Date of contactMethod of contactJob titleFull name of person contactedFace-to-facePhoneJob applied forEmployer nameEmployer phone number)(StateStreet addressCity9-digit ZIP Code, one of the Justices of theNumber of miles traveledFollow-up dateEmployer responseYesNoPossibleCourt in Witness, Honorableday of, 20 County,14Date of contactMethod of contactJob titleFull name of person contactedFace-to-facePhoneJob applied forEmployer nameEmployer phone number(Attorney must sign above and type name below))(StateStreet address9-digit ZIP CodeCityNumber of miles traveledFollow-up dateEmployer responseYesNoPossibleAttorney(s) for15Date of contactMethod of contactJob titleFull name of person contactedFace-to-facePhoneJob applied forEmployer nameEmployer phone number)(StateStreet address9-digit ZIP CodeCityOffice and P.O. AddressNumber of miles traveledFollow-up dateEmployer responseYesPossibleNoTelephone No.: Facsimile No.: E-Mail Address:I,theinjuredworker,certifythattheinformationrecordedonthisRecordofJobSearchContactsistrue.SIGNATURE:DATE:Distribution: