§ Form No. 15 Designation of record for review of an order of the Workers' Compensation Court
Form No. 15. Designation of record for review of an order of the Workers' Compensation Court
IN THE WORKERS' COMPENSATION COURT
OF THE STATE OF OKLAHOMA
_________________________, )
)
Claimant, )
) W.C.Ct. No. __________.
v. )
)
_________________________, )
)
Respondent, )
)
_________________________ )
Insurance Carrier. )
(If applicable)
DESIGNATION OF RECORD FOR REVIEW OF AN ORDER OF THE WORKERS' COMPENSATION COURT
___ Designation of Record
___ Counter-Designation of Record
___ Amended Designation of Record
A. DESIGNATION OF RECORD AND TRANSCRIPTS
[Claimant or Respondent or Insurance Carrier] _______ hereby designates the following for inclusion in the record for the Supreme Court's review in this case:
B. DATE, SIGNATURE, AND SERVICE BY COUNSEL OR PARTY
DATE: _______________, 19___.
Signature: _______________________________________________
(Signature of Attorney or Pro Se Party)
Attorney for _______________________________________________
(Claimant, Respondent, or Insurance Carrier)
OBA No.: _______________________________________________
Firm: _______________________________________________
Address: _______________________________________________
_______________________________________________
_______________________________________________
Telephone: _______________________________________________
CERTIFICATE OF SERVICE
I, _______ , hereby certify that in addition to filing the original Designation of Record with the Clerk of the Workers' Compensation Court a copy of the foregoing Designation of Record was mailed by first class mail, postage prepaid, this ___ day of _______ 199___, to the following:
[Names and Addresses of all parties or their counsel of record]
________________________________________________________________________________
Adopted July 10, 1996
Effective January 1, 1997
Heading renumbered by order of May 5, 2005, which added a new Part IX.