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West Virginia House of Delegates
APPLICATION FOR TEMPORARY (60-DAY) EMPLOYMENT
2017 Regular Session

February 8 - April 8, 2017

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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