Form R-25 "Qualified Rehabilitation Consultant Application" - Minnesota

What Is Form R-25?

This is a legal form that was released by the Minnesota Department of Labor and Industry - a government authority operating within Minnesota. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2015;
  • The latest edition provided by the Minnesota Department of Labor and Industry;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form R-25 by clicking the link below or browse more documents and templates provided by the Minnesota Department of Labor and Industry.

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Download Form R-25 "Qualified Rehabilitation Consultant Application" - Minnesota

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Minnesota Department of Labor and Industry
R-25
Financial Services
443 Lafayette Road N.
St. Paul, MN 55155
Qualified Rehabilitation Consultant
(651) 284-5083 or
1-800-342-5354
Application (check one)
www.dli.mn.gov
Initial registration
Renewal
Reinstatement
Print in ink or type
Applicant’s name
Telephone number
Employer
Telephone number
Employer’s address
Home address (
)
where certified mail can be delivered
Public mailing address (
)
City
State
ZIP code
if different from home address
City
State
ZIP code
Work email address
Applicant’s Minnesota tax ID number (if applicable)
QRC number
QRC expiration date Firm number
Applicant’s Social Security number
Professional license, certification, registration (check all that apply)
CRC
CDMS
CRRN
OTR
Attach a current copy of each license, certificate or registration.
FOR REINSTATEMENT APPLICATIONS ONLY
If you are applying for reinstatement of registration, you must provide verification of all of the following (Minnesota Rules
5220.1500, subp. 4):
A. current certification as required by Minn. Rules 5220.1400;
B. attendance at the most recent update session or a recording of that session;
C. documentation of continuing education requirements as provided by Minn. Rules 5220.1500, subp. 3a;
D. payment of any applicable late fees if the applicant failed to notify the commissioner that registration
renewal was not being sought; and
E. if the applicant has been on inactive status or has failed to renew registration for more than two years,
the applicant must also complete an orientation training session before acceptance is final.
Payment information: Enclose a check or money order for $100 payable to the “Minnesota Department of Labor and
Industry”. Send all application documents and fees to the department’s Financial Services unit at the above address.
MN R-25 (07/2015)
Reset
Minnesota Department of Labor and Industry
R-25
Financial Services
443 Lafayette Road N.
St. Paul, MN 55155
Qualified Rehabilitation Consultant
(651) 284-5083 or
1-800-342-5354
Application (check one)
www.dli.mn.gov
Initial registration
Renewal
Reinstatement
Print in ink or type
Applicant’s name
Telephone number
Employer
Telephone number
Employer’s address
Home address (
)
where certified mail can be delivered
Public mailing address (
)
City
State
ZIP code
if different from home address
City
State
ZIP code
Work email address
Applicant’s Minnesota tax ID number (if applicable)
QRC number
QRC expiration date Firm number
Applicant’s Social Security number
Professional license, certification, registration (check all that apply)
CRC
CDMS
CRRN
OTR
Attach a current copy of each license, certificate or registration.
FOR REINSTATEMENT APPLICATIONS ONLY
If you are applying for reinstatement of registration, you must provide verification of all of the following (Minnesota Rules
5220.1500, subp. 4):
A. current certification as required by Minn. Rules 5220.1400;
B. attendance at the most recent update session or a recording of that session;
C. documentation of continuing education requirements as provided by Minn. Rules 5220.1500, subp. 3a;
D. payment of any applicable late fees if the applicant failed to notify the commissioner that registration
renewal was not being sought; and
E. if the applicant has been on inactive status or has failed to renew registration for more than two years,
the applicant must also complete an orientation training session before acceptance is final.
Payment information: Enclose a check or money order for $100 payable to the “Minnesota Department of Labor and
Industry”. Send all application documents and fees to the department’s Financial Services unit at the above address.
MN R-25 (07/2015)
I authorize the Workers’ Compensation Division, Department of Labor and Industry, to make any appropriate investigation
of the application and supporting documents. I understand that any omission or misrepresentation may result in rejection
of this application or denial of registration.
I agree to be bound by all statutes, rules and orders as established by the commissioner, and realize that violations may
result in the denial or revocation of registration.
I understand that Minn. Rules 5220.1250 prohibits any ownership or financial relationship of any kind between any
registered rehabilitation vendor and qualified rehabilitation consultant firm, qualified rehabilitation consultant or qualified
rehabilitation consultant intern.
I agree to notify the department immediately of any change in my employment status (Minn. Rules 5220.1400, subp. 5). If
there is a change in my employment status, I will notify all parties to the cases on which I am the assigned QRC as to
whom the reassignment will be made (Minn. Rules 5220.1801, subp. 9K(2)).
I certify that I am a full-time resident of Minnesota or I live no more than 100 miles by road from the Minnesota border
(Minn. Rules 5220.1400, subp. 5).
Notice: The information you as an individual provide in this application will be used by Department of Labor and Industry
(department) staff members who require the information to determine if you meet the department’s registration/renewal
requirements. Minnesota Statutes § 270C.72, subd. 4, requires you to provide your Social Security number and
Minnesota tax identification number on this application. The other information is being requested for purposes of
processing your application. With the exception of your Social Security number and Minnesota tax identification number,
you are not legally required to supply the data requested on this application. However, failure to provide the requested
information may delay the processing of your application or result in the denial of the same. The application data will be
made part of the department’s file for your registration/renewal. Except for your name and the address you designated to
receive correspondence from the department, the information you provide on this application is private data while the
application is pending. Once you are registered, the application data may become public except for your Social Security
number and Minnesota tax identification number. However, disclosure of private or nonpublic information to others may
occur as authorized or required by law, including but not limited to the Attorney General’s Office, the Department of
Revenue, the Office of Administrative Hearings, upon court order, and/or for the purpose of verification, state
investigations and statistics.
Applicant signature
Date
This form is located at www.dli.mn.gov/WC/Wcforms.asp. The form can be made available in different formats, such as
large print, Braille or audio. To request, call (651) 284-5032 or 1-800-342-5354
.
MN R-25 (07/2015)
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