House Per Diem West Virginia House of Delegates - Application for Temporary 60-Day Employment - 2022 Regular Session CONTACT INFORMATIONName(Required) First Last Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneEmail PERSONAL HISTORYOccupationWork most qualified to perform:Have you ever been convicted of a Felony?(Required) NO YES DetailsEDUCATIONHighest education level attained(Required) Middle School High School College Graduate Other Specifics of advanced studiesMajorDegreeCOMPUTER SKILLSWhat software programs are you proficient in?How many words per minute can you type?EMPLOYMENT HISTORYLast EmployerAddressSupervisorLast Position HeldEmployed From MM slash DD slash YYYY To MM slash DD slash YYYY Do you have another Employer to add? No Yes Previous EmployerAddressSupervisorLast Position HeldEmployed from MM slash DD slash YYYY To MM slash DD slash YYYY PERSONAL REFERENCESCannot be former employers or relatives1. ReferenceName(Required)AddressOccupationPhone(Required)2. ReferenceName(Required)AddressOccupationPhone(Required)NameThis field is for validation purposes and should be left unchanged.
