Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Enterprise Services F-80911A (07/08)

STATE OF WISCONSIN

INSTRUCTIONS FOR LIMITED TERM EMPLOYMENT (LTE) APPLICATION, F-80911
Social Security Number: Social Security Numbers are used in our LTE database to match individuals and their application information file. Providing your Social Security Number is voluntary; however, we must have a nine-digit number to process your LTE Information Form. Persons not wanting to disclose their Social Security Number must attach a letter to their LTE Information Form requesting the Department of Health Services provide a nine-digit number to be used for processing purposes. The LTE Information Form will not be processed without the Social Security Number or the letter of request for an assigned nine-digit number. Racial/Ethnic 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 Pacific Islands. American Indian or Alaska Native: Persons descending from any of the original peoples of North America who possess 1/4 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: Persons not of Hispanic origin. All persons having origins in any of the original peoples of Europe, North Africa or the Middle East. Note: Applicants may be required to provide verification of racial/ethnic status claimed. Persons with Disabilities: 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 accommodations for qualified individuals with disabilities who are applicants for employment. If you need special accommodations, please contact our office at (608) 266-3356 or (888) 701-1251 (Textnet). Veteran Status: You are considered a veteran or a veteran with a disability if you have been honorabley 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. 99 Served for at least two continuous years on active duty under honorable conditions; or the full period of 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 war period or campaign.

Active service for at least one day during one of the following wartime periods: 01. 02. 03. 04. 05. 06. 07. August 27, 1940 - July 25, 1947 June 27, 1950 - January 31, 1955 August 5, 1964 - July 1, 1977 1961 Berlin Crisis - 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 1 of Executive Order 10957 Persian Gulf War/Desert Shield/Desert Storm August 1, 1990 to Date to be determined Afghanistan War - Sept. 11, 2001 to date to be determined Iraq War ­ March 19, 2003 to date to be determined

or are 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: 10. Berlin: August 14, 1961 - June 1, 1963 20. Middle East Crisis: See ss.45.34(2), Wis. Stats. 11. Congo: July 14, 1960 - September 1, 1962 21. Operation Just Cause, Panama: 12. Cuba: October 24, 1962 - June 1, 1963 December 20, 1989 - January 31, 1990 13. Grenada: October 23, 1983 - November 21, 1983 22. Operation Restore Hope, Somalia: 14. Laos: April 19, 1961 - October 7, 1962 December 9, 1992 - Date to be determined 15. Lebanon: July 1, 1958 - November 1, 1958 23. Bosnia: December 1, 1995 ­Date to be determined 16. Lebanon: August 1, 1982 - August 1, 1984 24. Operation Enduring Freedom: 17. Quemoy and Matsu: August 23, 1958 - June 1, 1963 September 11, 2001 ­ Date to be determined 18. Taiwan Straits: August 23, 1958 - January 1, 1959 19. Vietnam: July 1, 1958 - August 4, 1964