Free None - Wisconsin

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

STATE OF WISCONSIN

LIMITED TERM EMPLOYMENT (LTE) APPLICATION
This form is used to enter applications into the LTE Referral System. Date of birth, gender, race/ethnicity and disability status information is for equal opportunity/affirmative action reporting and planning. Please complete both pages of this form and submit it to the Department of Health Services, BPER, One W. Wilson Street, Room 555, P.O. Box 7850, Madison WI 53707-7850.

The Department of Health Services is an equal opportunity employer functioning under an affirmative action plan. Last Name Street Address / P.O.Box City First Name County State Zip Code Middle Initial

Social Security Number See Instructions, F-80911A, for detailed information. Home Telephone Number Work Telephone Number Cell Telephone Number Disability Status See instructions, F-80911A, for detailed information. Do you consider yourself a person with a disability? Yes No

Race / Ethnicity ­ See Instructions, F-80911A, for detailed information. 1 ­ Black (Not Hispanic) 2 ­ Asian or Pacific Islander 3 ­ American Indian / Alaska Native 4 ­ Hispanic 5 ­ White (Not Hispanic)

Date of Birth Gender ­ Check One Male Female VETERAN INFORMATION ­ See instructions, F-80911A, for detailed information. If you are a qualified veteran, enter the number code which Are You a Veteran? Yes No indicates qualifying date and campaign.

WISCONSIN WORKS (W-2) ­ Check applicable response for each question Are you a food stamp customer with dependent children? Are you currently receiving W-2? Yes No Yes No EMPLOYMENT AVAILABILITY ­ Check all that indicate the type / time of employment you would consider Employment Type Full Time ­ 40 hrs./week Part Time ­ 1 to 20 hrs./week Part Time ­ 21 to 40 hrs./week Employment Time Day Hours Evening / Night Hours ­ 3:00PM ­ 7:00 AM Weekend Hours Summer Employment Only - May through August EMPLOYMENT AREAS
The state is divided into 72 counties. Cities with a population of more than 100,000 have the following codes: · 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 Using this map Enter county codes in which you will accept employment

F-80911, P.2 Listed below are classifications in which Limited Term Employment vacancies may occur. Please check the classifications that you would consider. Do NOT indicate classifications for which you do not have basic qualifications or that require licenses or journey cards which you do not have. See P-80043 for more information on the various classifications

Accountant Administrative Manager Attorney Auditor Automotive/Equipment Technician Barber Bricklayer & Mason Budget and Policy Analyst CADD Specialist Carpenter Chaplain Clerical Assistant Clerical Helper LTE Client Rights Facilitator Client Rights Specialist Client Services Assistant Communications Specialist Cook Custodian Dental Assistant Dental Consultant LTE Developmental Disabilities Coordinator Developmental Disabilities Specialist Dietitian Clinical Disability Associate Disability Claims Reviewer Disability Claims Specialist Disability Determination Specialist Disability Program Associate Document Production Assistant Economic Support Specialist Electrician Environmental Health Specialist Equal Opportunity Specialist Facilities Maintenance Specialist Facilities Repair Worker Financial Clerk Financial Specialist Food Production Assistant Food Service Assistant Groundskeeper

Health Care Rate Analyst Human Resources Assistant Human Resources Specialist Human Services Program Coordinator Inventory Control Assistant IS Professional IS Technician Laborer Laundry Worker Legal Associate Legal Secretary Librarian Library Services Assistant License / Permit Program Associate Licensed Practical Nurse Licensing/Certification Specialist Locksmith Mechanician Motor Vehicle Operator Nurse Clinician Nursing Assistant Nursing Consultant Nursing Specialist Occupational Therapist Occupational Therapy Asst Office Associate Office Operations Associate Painter Paralegal Payroll & Benefits Specialist Pharmacist Pharmacy Technician Phlebotomist Physical Therapist Physical Therapy Assistant Physician Plumber Power Plant Assistant Power Plant Operator Professional Consultant LTE Program & Planning Analyst

Psychiatric Care Technician Psychiatrist Psychological Associate Psychological Consultant LTE Psychological Services Assistant Psychologist - Licensed Psychologist Intern LTE Public Health Educator Public Health Nurse Public Health Nutritionist Public Health Sanitarian Publications Editor Purchasing Agent Quality Assurance Program Specialist Recreation Assistant Recreation Leader Regulatory Specialist Rehabilitation Case Manager Research Analyst Research Technician Resident Care Technician Respiratory Therapist Seamer Security Officer Shipping and Mailing Associate Social Services Specialist Social Worker Special Activities Helper LTE Steamfitter Substance Abuse Counselor Teacher Teacher Assistant Temporary Nurse LTE Therapist Therapy Assistant Training Officer Treatment Specialist Upholsterer Volunteer Coordinator

The information provided on this form identifies the type of employment, job classifications and employment areas of the state for which I am willing to consider employment. I affirm that the information I provided on this form is true to the best of my knowledge; that I may be required to verify the information prior to appointment; and that any false, misleading or missing information may disqualify me from employment consideration. I have included my Social Security Number on this form or have attached a letter of request as discussed on the enclosed information.

SIGNATURE - Applicant

Date Signed