PERSONAL INFORMATION:
Full Name: 

  Date of Birth Sex:

Email Address:

Phone:

PRESENT ADDRESS:

 Street Apt. City:   State: Zip:

PERMANENT ADDRESS:

Street: Apt. City: State: Zip:  

Phone:

EDUCATION:

High School (name and location)

Dates Attended Grade Completed

College (name and location)

 Dates Attended Grade Completed

Additional Education_ 

Dates Attended Grade Completed

WORK EXPERIENCE:

Present/Most Recent Employer_

Address:

Employed from:    To:

Duties 

Reason for leaving:

JOB PRIOR: 

Employer

Address:  

Employed from:   To:

Duties

Reason for leaving:

GENERAL INFORMATION:

Employment_ Sought  Full Time Part Time Either

If part time, list preference Mornings Mid-day Afternoon

Date available

Are you a US Citizen? Yes No

Are you a state Resident? Yes No

Do you have a valid driver's license? Yes No   What State?

REFERENCES:

Name

Address Phone

Name

Address Phone

The Wisconsin State Senate is committed to providing equal employment opportunity in all terms, conditions, or privileges of employment, including but not limited to: recruitment; certifications; selections; job assignments; working conditions; fringe benefits; compensation; training; transfer; layoffs; disciplinary actions; terminations or promotions. It is the policy of the State Senate to promote fair and equitable treatment of all employees and to comply with federal and state legislation.

May we conduct a Personal__ background check including contact of your references and review other records as may be required for some positions?

Yes No

If no, please explain: