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West Virginia House of Delegates
APPLICATION FOR TEMPORARY (60-DAY) EMPLOYMENT
2013 Regular Session

February 13 - April 13, 2013

Office of the Speaker
Room 228, State Capitol
Charleston, WV 25305
304-340-3210

Fields in RED are required!
First Name:
Middle Initial:
Last Name:
Street Address:
 City:
 Zip:
County:
Home Phone:(eg. 555-5555)
Office Phone:(eg. 555-5555)
Occupation:


Have you ever been convicted of a Felony
Yes No
If Yes, explain:


Work most qualified to perform:


Education
Check highest education level attained:

Middle School
High School
College
Graduate

Specifics of advanced studies (if applicable)
Major:
Degree:
Other:


Computer Skills
Word processing (words per minute):
Program:
Other Programs:


Employment History
Last Employer
Address:
Supervisor:
Last position held:
Employed from: (eg. 06/12/98)
to: (eg. 11/06/00)


Previous Employer
Address:
Supervisor:
Last position held:
Employed from: (eg. 06/12/98)
to: (eg. 11/06/00)


Previous Employer 2
Address:
Supervisor:
Last position held:
Employed from: (eg. 06/12/98)
to: (eg. 11/06/00)


Personal References (Not former employers or relatives)
1.
Name:
Address:
Occupation:
Phone: (eg. 304-555-5555)


2.
Name:
Address:
Occupation:
Phone: (eg. 304-555-5555)






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