Free WkC-34.PDF - Wisconsin

License Application

Department of Workforce Development Worker's Compensation Division 201 E. Washington Ave., Rm. C100 P.O. Box 7901 Madison, WI 53707-7901 Telephone: (608) 266-1340 Fax: (608) 267-0394 http://www.dwd.state.wi.us/wc/ e-mail: [email protected]

Personal information you provide may be used for secondary purposes, (Privacy law, s. 5.04(1)(m).

I am applying for license to appear before the department under provisions of the Worker's Compensation Act. Applicant Name Applicant SS # or FEIN # (Required per s. 102.17(1)(cg)) Applicant Telephone No. ( Applicant Address City State ) Zip Code

Have you ever been convicted of a felony?

Yes

No If yes, on the lines below briefly state the particulars:

______________________________________________________________________________________________________ ______________________________________________________________________________________________________

Have you ever been disbarred from the practice of law or resigned upon request of constituted authorities? Yes No If yes, by what authority?

If disbarred or resigned, have you been reinstated to practice? Yes No If yes, give date: ___________________ _______________________________

_____________________________________________ For what cause were you disbarred or resigned? _____________________________________________

In which states?

____________________________________________

Below, give an outline of your employment record, showing your present or last position first. List all your principal work and every full-time position you have held in the last 3 years. Position Held From: Employer Address Position Held From: Employer Address Position Held From: Employer Address Position Held From: Employer Address To: City Employer To: City Employer To: City Employer To: City Employer Employer Phone Number ( State ) Zip Code

Employer Phone Number ( State ) Zip Code

Employer Phone Number ( State ) Zip Code

Employer Phone Number ( State ) Zip Code

WKC-34 (R. 07/2001)

(Over)

Provide Three Non-Family References: Name Phone Number (
Address City

)
State Zip Code

Name

Phone Number ( )
State Zip Code

Address

City

Name

Phone Number ( )
State Zip Code

Address

City

Provide a brief statement of your background, training or experience (if any) in Worker's Compensation matters _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________

For the 3 hearings at which you have been permitted to appear without a license, provide the following:

Hearing Date

Case Name

Party You Represented

I certify that the above statements are true to the best of my knowledge and belief.

Applicant Signature __________________________________________ Date Signed ___________________________