House Per Diem - Entry Form

West Virginia House of Delegates
APPLICATION FOR TEMPORARY (60-DAY) EMPLOYMENT
2022 Regular Session

January 12 - March 12, 2022

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

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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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