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DEPARTMENT OF HEALTH SERVICES F-82006 (07/08)

STATE OF WISCONSIN

EMPLOYMENT APPLICATION SUPPLEMENT
AN EQUAL OPPORTUNITY EMPLOYER FUNCTIONING UNDER AN AFFIRMATIVE ACTION PLAN 1. A copy of all Employment Application Supplement forms marked LTE or Project should be sent to the Department of Health Services, Affirmative Action / Civil Rights Office, 1 West Wilson Street, P O Box 7850, Madison WI 53707-7850. 2. See page 4 for further instructions. Application Date Job Announcement Code Position Title Name ­ Applicant Area Code / Cell Telephone Number Area Code / Home Telephone Number Area Code / Work Telephone Number Instructions:

( ( )
Yes No

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Social Security Number (See attached instructions)

Birthdate (For administrative purposes only)

Are you a Wisconsin resident?

Mailing Address ­ Street / P.O. Box / Rural Route, City, State, Zip + 4

Wisconsin residency is required for LTE and Project employment Employment Preference Shift Preference Date Available for Employment Employment Type Permanent Project Full Time Part Time First Second Third Limited Term Employment (LTE) Do you have a valid Wisconsin driver's If a job opportunity requires, would Are you a U.S. citizen or do you possess appropriate work authorization? license or eligibility to obtain one? you be able to travel? Proof is required prior to being hired. Yes No Yes No Yes No Veterans Status (Check One if applicable) Disability Status If a qualified veteran, enter number code which indicates Do you consider yourself a person with a disability? qualifying date & campaign. See Instructions page for Veteran Yes No number codes. Disabled Veteran W2 Status Are you receiving W2? Yes No Have you received any issuance of W2 or Food Stamps within the past 12 months? Yes No

GENDER AND ETHNICITY / RACE INFORMATION Gender and ethnic / racial information is used for equal employment opportunity / affirmative action (EEO / AA) purposes only. If you do provide this information, you may be eligible for further consideration of job opportunities through the Department of Health Services EEO / AA Plan. Gender Male Female Ethnic / Racial Group (Check One) See Instructions page for detailed descriptions. 1. Black (not of Hispanic Origin) 3. American Indian / Alaskan Native 2. Asian or Pacific Islander 4. Hispanic (Mexican, Puerto Rican (Includes Indian Subcontinent Origin) or Other Spanish Culture) FORMAL EDUCATION / TRAINING BEYOND HIGH SCHOOL Dates Attended Major / Minor Field(s) Degree Organization ­ Name and Location From To 5. White

Year

SPECIAL QUALIFICATIONS Foreign Language(s) ­ List Language Skill(s)

Verbal

Written

Current License / Registration Memberships ­ List Name(s) of Professional / Technical Association(s)

Computer Skills (Check appropriate Box(es)) Yes No Data Entry Word Processing

List Programming Languages ­ TRNG. EXP.

List Software Experience ­

TRNG. EXP.

OTHER SKILLS / QUALIFICATIONS (Include typing / shorthand speed, office skills / machines, technical vocabulary, etc.)

GEOGRAPHIC LOCATIONS(S) YOU WILL CONSIDER FOR EMPLOYMENT. Enter 2 or 3 Digit County Code(s) Below Using the Information on Page 3. County Code(s)

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F-82006 Page 2 of 4 EMPLOYMENT HISTORY ­ This section must be completed even if you supply a resume. (In chronological order, list most recent employment first. Include all employment for the last 10 years. If necessary, attach additional sheets using the following format.) Duties / Responsibilities Name ­ Employer Street Address City Supervisor Title Dates of Employment From Hours Per Week Full Time Name ­ Employer Street Address City Supervisor Title Dates of Employment From Hours Per Week Full Time Name ­ Employer Street Address City Supervisor Title Dates of Employment From Hours Per Week Full Time Name ­ Employer Street Address City Supervisor Title Dates of Employment From Hours Per Week Full Time State Zip Code State Zip Code Part Time Volunteer Duties / Responsibilities To State Zip Code State Zip Code

Telephone Number

To Part Time Volunteer Duties / Responsibilities

Telephone Number

Telephone Number

To Part Time Volunteer Duties / Responsibilities

Telephone Number

To Part Time Volunteer

I understand that all the information on this application is true and complete to the best of my knowledge and that any false or missing job related information may disqualify me for this position. SIGNATURE ­ Applicant Date Signed

F-82006 Page 3 of 4

WHERE YOU WOULD LIKE TO WORK
Select the desired code(s) below for the county or counties where you will accept work and transfer that two-digit number to the front of this Employment Application Supplement. See map below. We will consider you only for jobs in the locations where you tell us you will work. You must enter at least one code for us to process your application. Code County 01 ­ 02 ­ 03 ­ 04 ­ 05 ­ 06 ­ 07 ­ 08 ­ 09 ­ 10 ­ 11 ­ 12 ­ 13 ­ 13a ­ Adams Ashland Barron Bayfield Brown Buffalo Burnett Calumet Chippewa Clark Columbia Crawford Dane Mendota Mental Health Institute only 13b ­ Central Wisconsin Center only Code County 14 ­ Dodge 15 ­ Door 16 ­ Douglas 17 ­ Dunn 18 ­ Eau Claire 19 ­ Florence 20 ­ Fond du Lac 21 ­ Forest 22 ­ Grant 23 ­ Green 24 ­ Green Lake 25 ­ Iowa 26 ­ Iron 27 ­ Jackson 28 ­ Jefferson 29 ­ Juneau 30 ­ Kenosha 31 ­ Kewaunee 32 ­ La Crosse Code County 33 ­ Lafayette 34 ­ Langlade 35 ­ Lincoln 36 ­ Manitowoc 37 ­ Marathon 38 ­ Marinette 39 ­ Marquette 40 ­ Menominee 41 ­ Milwaukee 42 ­ Monroe 43 ­ Oconto 44 ­ Oneida 45 ­ Outagamie 46 ­ Ozaukee 47 ­ Pepin 48 ­ Pierce 49 ­ Polk 50 ­ Portage 51 ­ Price Code County 52 ­ Racine 53 ­ Richland 54 ­ Rock 55 ­ Rusk 56 ­ Saint Croix 57 ­ Sauk 58 ­ Sawyer 59 ­ Shawano 60 ­ Sheboygan 61 ­ Taylor 62 ­ Trempealeau 63 ­ Vernon 64 ­ Vilas 65 ­ Walworth 66 ­ Washburn 67 ­ Washington 68 ­ Waukesha 69 ­ Waupaca 70 ­ Waushara Code County 71 ­ Winnebago 71a ­ Winnebago Mental Health Institute only 71b ­ Wisconsin Resource Center only 72 ­ Wood 99 ­ All Counties

Cities with population of more than 100,000: · Madison (state capital) is in Dane County, code 13 Milwaukee (largest city) is in Milwaukee County, code 41 Green Bay is in Brown County, code 05

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F-82006 Page 4 of 4

INSTRUCTIONS

SOCIAL SECURITY NUMBER
Social Security numbers are used in our applicant computer system to match individuals and their application/examination file. Giving your Social Security number is voluntary; however, we must have a nine-digit number to process your application. Persons not wanting to divulge their Social Security number must attach a letter to their application stating that they request the State Department of Health Services to provide a nine-digit number for them to be used for application purposes only. LTE/Project Employment forms will not be processed without either the Social Security number or the letter of request for an assigned nine-digit number.

ETHNIC/RACIAL CODE DEFINITIONS
Black ­ Not of Hispanic origin. All persons having origins in any of the Black racial groups of Africa. Asian or Pacific Islander ­ All persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent, or the Pacific Islands. American Indian or Alaskan Native ­ Persons descending from any of the original peoples of North America who possess ¼ degree of documented tribal descent or are enrolled with a federally or state recognized tribe, or are recognized by a federally or state recognized tribe as American Indians for state affirmative action purposes. Hispanic ­ All persons of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture or origin, regardless of race. White ­ Not of Hispanic origin. All persons having origins in any of the original people of Europe, North Africa, or the Middle East. NOTE: Applicants may be required to provide verification of ethnic/racial status claimed.

PERSONS WITH DISABILITES
An individual is considered to have a disability if he/she: a. has a physical or mental impairment which makes achievement unusually difficult or limits the capacity to work or which limits one or more major life activity; or b. has a record of such an impairment. An individual may be completely free from a previous physical or mental impairment, but may still have difficulty in job situations because of medical history; or c. is perceived as having such an impairment by those who can have an effect on the individual's chance to secure, retain, or advance in employment, whether or not an actual impairment exists.

REASONABLE ACCOMMODATION
The Department of Health Services will not deny employment to anyone because of the need to make reasonable accommodation for qualified individuals with disabilities who are applicants for employment. If you need special accommodations for an interview, please contact the supervisor who offered the interview. Hearing impaired individuals may call the TTY line at (608) 266-2555.

VETERAN STATUS
You are considered a veteran or a veteran with a disability if you have been honorably discharged from the U.S. Armed Forces and/or you have a service connected disability recognized by the U.S. Veterans' Administration and resulting from active service in any of the areas and during any service period listed below.

- I had active service for at least one day during one of the following wartime periods.
01 ­ 02 ­ 03 ­ 04 ­ August 27, 1940, to July 25, 1947 June 27, 1950, to January 31, 1955 August 5, 1964, to July 1, 1975 I served on active duty as a member of the Reserve or National Guard who was ordered to active duty because of the 1961 Berlin Crisis under Section I of Executive order 10957 17 ­ Persian Gulf War/Desert Shield/Desert Storm (August 1, 1990 to date to be determined)

- or I am entitled to the Armed Forces, Navy, or Marine Corps Expeditionary Medal or the Vietnam Service Medal for participation in the following campaigns that occurred within the inclusive dates indicated
05 ­ Berlin..................................................................August 14, 1961 to June 1, 1963 06 ­ Congo............................................................July 14, 1960 to September 1, 1962 07 ­ Cuba.................................................................October 23, 1962 to June 1, 1963 08 ­ Grenada...................................................October 23, 1983 to November 21, 1983 09 ­ Laos..................................................................April 19, 1961 to October 7, 1962 10 ­ Lebanon............................................................July 1, 1958 to November 1, 1958 11 ­ Lebanon............................................................August 1, 1982 to August 1, 1984 12 ­ Quemoy and Matsu...............................................August 23, 1958 to June 1, 1963 13 ­ Taiwan Straits..................................................August 23, 1958 to January 1, 1959 14 ­ Vietnam.................................................................July 1, 1958 to August 4, 1964 15 ­ Middle East Crisis.........................................................See S 45.34(2), Wis. Stats. 16 ­ Operation Just Cause ­ Panama...................December 20, 1989 to January 31, 1990 18 ­ Operation Restore Hope ­ Somalia............December 9, 1992 to date to be determined 19 ­ Bosnia..................................................December 1, 1995 to date to be determined 20 ­ or I served for at least two continuous years on active duty under

honorable conditions; or the full period of my initial service obligation; or was discharged or released after less than two years due to hardship; a service-connected disability or a reduction in the armed forces. Service did not have to occur during a specified war period or campaign.