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November 4, 2008    DOL Home > Find It! By Form > DOL Form  

DOL Form EEOICP EE-4

View ESA-OWCP-EEOICP's Form 1215-0197 Online htm
Agency: ESA-OWCP-EEOICP
Title: EEOICP EE-4, Employment History Affidavit for Claim Under Energy Employees Occupational Illness Compensation Program Act
Form Description: EEOICP EE-4, Employment History Affidavit for Claim Under Energy Employees Occupational Illness Compensation Program Act: Applicants use this form to submit an Employment History Affadavit for a claim under the EEOICPA.
OMB Control Number: 1215-0197
OMB Expiration Date: Tuesday, August 31, 2010

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