Personal Information First Name * Middle Initial * Last Name * Primary Phone Number * Cell Phone (if different) Email Address * Home Address Line 1 * Home Address Line 2 City * State * AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code * Date of Birth Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year1868186918701871187218731874187518761877187818791880188118821883188418851886188718881889189018911892189318941895189618971898189919001901190219031904190519061907190819091910191119121913191419151916191719181919192019211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018 State Senator * State Representative * Company Name * Job Title * Work Address Line 1 * Work Address Line 2 City * State * AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code * Work Phone Number * Work Fax Number What is your state of residence? * AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Preferred Mailing Address * Home Work Are you a state employee? * Yes No If yes, list your Department and Division * Are you an elected official? * Yes No If yes, what is your position? * Are you a licensed/certified professional? * Yes No If yes, please specify * Do you belong to any professional groups? * Yes No If yes, please specify * Demographic Information Is Optional Disability Veteran Yes No Gender Male Female Ethnicity Appointment Information Appointment Sought * In the space provided below, please list the names of three people who are willing to serve as references. Please also include phone numbers and their relationship to you. First Reference Name * Phone Number * Relationship to You * Second Reference Name * Phone Number * Relationship to You * Third Reference Name * Phone Number * Relationship to You * Did anyone refer you to this appointment? * Yes No If yes, who? * Cover Letter * Please attach a copy of your cover letter to this application.Files must be less than 2 MB.Allowed file types: txt pdf doc docx. Upload Resume * Please attach a copy of your resume to this application. Please include all relevant work experience, education, community involvement, government or military service, honors, awards and other talents.Files must be less than 2 MB.Allowed file types: txt pdf doc docx. Upload By submitting this application you are affirming that all the statements you have made in this document are true and that you understand that an extensive background check may be conducted if you are considered for appointment. Under Wisconsin Statutes 19.36 (7)(b), as an applicant for this position, you have the limited right to request that your identity be kept in confidence. If you wish to preserve this right, you must attach to your application a letter requesting confidentiality of your identity with respect to this application. This right prevents your identity from being released in response to a public records request unless; you are appointed to the position or you are a finalist for the position as defined by Wisconsin Statute 19.36(7)(a). Leave this field blank Submit
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