Fill and Sign the License Application for Workers Compensation Wisconsin Form

Yes No If yes, on the lines below briefly state the particulars. Yes No If yes, by what authority? Yes No If yes, give date.                                                                                                       In which states?                                                                                                                                                                                                                  ( ) ( ) ( ) ( ) ( ) License Application Department of Workforce Development Worker's Compensation Division 201 E. Washington Avenue, Rm. 161P.O. Box 7901Madison, Wl 53707-7901Telephone: (608) 266-1340 Personal information you provide may be used for secondary purposes, (Privacy law, s. 5.04(l)(m). 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 Cit y State Zip Code Have you ever been convicted of a felony? Have you ever been disbarred from the practice of law or resigned upon request of constituted authorities? If disbarred or resigned, have you been reinstated to practice? For what cause were you disbarred or resigned? 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. Position Held Employe r Employer Phone Number From: To: Employer Address City State Zip Code Position Held Employe r Employer Phone Number From: To: Employer Address City State Zip Code Position Held Employe r Employer Phone Number From: To: Employer Address City State Zip Code Position Held Employe r Employer Phone Number From: To: Employer Address Cit y State Zip Code WKC-34 (R. 11 /98) (Over) Hearing Date Case Name Party You Represented                                                                                                                                                                                   Date Signed      ( ) ( ) ( )Non-Family References - Give 3 Name Phone Number Address City State Zip Code Name Phone Number Address City State Zip Code Name Phone Number Address City State Zip Code 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: I certify that the above statements are true to the best of my knowledge and belief. Applicant Signature