Previous Employment Verification Form
ADVERTISEMENT
1State of Wisconsin
Scott Walker
Governor
Higher Educational Aids Board
P.O. Box 7885
Telephone: (608) 267-2206
Madison, WI 53707-7885
Fax: (608) 267-2808
John Reinemann
Executive Secretary
E-Mail: HEABmail@wisconsin.gov
Web Page:
PREVIOUS EMPLOYMENT VERIFICATION FORM
Section A: To be completed by Applicant
Name: ___________________________________________________________________________
Name of Employer: ________________________________________________________________
Address: _________________________________________________________________________
City: ________________________________________ State: ______________ Zip: _________
Job Title: ________________________________________________________________________
Brief Description of Work: __________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
I authorize the above-named employer to provide the information requested in Section B of this
form:
______________________________________________
_______________________
Applicant Signature
Date
Section B: To be completed by Employer
The JRJ Student Loan Repayment Program requires information about the applicant’s job history and certification of an
applicant’s employment. Please complete this section of the form and return it to the employee.
Description of Agency’s Primary Function*:_____________________________________________
_______________
______________
Years __________ Months _______
Date of Hire
Date of Separation
Length of Employment
___________________________________
__________________________________________
Name of person certifying employment
Title
(PLEASE PRINT)
I certify that information contained in this form is true and complete to the best of my knowledge.
__________________________________________
______________________________
Signature
Date
*
Pursuant to program guidelines, qualifying employment includes working as a full-time (at least 30 hours) prosecutor in criminal or
juvenile delinquency cases for a state, local or tribal government; or working full-time providing legal representation to indigent
persons in criminal or juvenile delinquency cases for a stat, local or tribal government, or a non-profit organization operating under
a contract with a state or local government, or a full-time federal defender in a defender organization under Subsection (g) of
section 3006A of Title 18, U.S. Code, and including full-time employees who supervise, educate or train other persons prosecuting or
providing representation as described.
2014-RJ-BX-0013
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal