Fill and Sign the Wkc 34 Wisconsin Department of Workforce Development Form

*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? _____________________________________________ For what cause were you disbarred or resigned? _____________________________________________ If disbarred or resigned, have you been reinstated to practi ce? Yes No If yes, give date: ___________________ In which states? _______________________________ ____________________________________________ Below, give an outline of your employment record, showing your p resent or last position first. List all your principal work and every full -time position you have held in the last 3 years. Position Held From: To: Employer Employer Phone Number ( ) Employer Address City State Zip Code Position Held From: To: Employer Employer Phone Number ( ) Employer Address City State Zip Code Position Held From: To: Employer Employer Phone Number ( ) Employer Address City State Zip Code Position Held From: To: Employer Employer Phone Number ( ) Employer Address City State Zip Code WKC -34 (R. 06/20 17) (Over) 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 License A pplication Provide Three Non -Family References: 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 W orker’s Compensation matters _______________________________________________________ __________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ ______________ ___________________________________________________________________________________ _________________________________________________________________________________________________ For the 3 hearings at which you have been permitted to appear witho ut 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 __________________________________________ D ate Signed ___________________________