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Complete Section A if you are an INDIVIDUAL PROVIDER enrolling to provide services for one of the Department of Labor Office of Workers Compensation Programs: FCA, Energy, or Black Lung. Please Note:
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What is Check the appropriate application type:New EnrollmentRe-Enrollment orUpdate Form?

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The check form appropriate application is a document used to submit information for appropriate checks.
Individuals or organizations required to undergo appropriate checks are required to file check form appropriate applications.
The check form appropriate application can be filled out by providing accurate and complete information as requested on the form.
The purpose of the check form appropriate application is to gather necessary information for conducting appropriate checks.
Personal or organizational details as required for appropriate checks must be reported on the form.
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