Wisconsin > Workers Comp
License Application WKC 34 - Wisconsin
| License Application Form. This is a Wisconsin form and can be used in Workers Comp . |
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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://dwd.wisconsin.gov/wc e-mail: DWDDWC@dwd.wisconsin.gov Provision of your Social Security Number (SSN) is voluntary. Failure to provide it may result in an information processing delay. Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04 (1)(m), Wisconsin Statutes]. 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. Employer Employer Phone Number 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 ( State ) Zip Code Employer Phone Number ( State ) Zip Code Employer Phone Number ( State ) Zip Code Employer Phone Number ( State ) Zip Code WKC-34 (R. 10/2009) (Over) American LegalNet, Inc. www.FormsWorkFlow.com 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 ___________________________ American LegalNet, Inc. www.FormsWorkFlow.com
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