Based on qualifications presented on your application form and/or in your job interview, you are hereby offered a job with our organization conditional upon verification of workers' compensation information.

___________________________________             ________________________________________________
Company Name					Employer's Signature

                                                                                    
                                                                                   
___________________________________             ________________________________________________
Job Position                                    Date of Job Offer



___________________________________
Employee's Signature






Note: This information is not to be used in a manner which would violate the Americans with Disabilities Act.


























LexisNexis Form-WC3


Revised 01/27/2009







  

    

    
    

    

      

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