The Wisconsin Technical College System (WTCS) Board requires that all educational personnel be certified on the basis of their education
and occupational experience. Self-employment is acceptable when verified by an attorney, accountant, banker, customer, client, or other
non-family member who has knowledge of the work performed. This information also applies to those who are renewing standard five year
certificates from the WTCS.

AUTHORIZATION: To be completed by Applicant/Employee.
Print Name: _____________________________

Social Security Number: _________________________

Business Name

Type of Business

Business Address

EMPLOYMENT RECORD: To be completed by Applicant/Employee and returned to address shown.
I certify that I was/am self-employed during this time frame:
From: (MM/DD/YYYY) _______________________



Full-Time hours worked to date:

Part-Time hours worked to date:

For ________ hours per week for _________ weeks.

For _______ hours per week for _________ weeks.

Total number of Full-Time hours employed to date:_______

Total number of Part-Time hours employed to date:______

Job Title/Classification:
List Primary Job Duties: (Attach position description if available)

Percentage of Time:







VERIFICATION: Applicant/Employee obtains verification from lawyer, accountant, banker, customer, client or
other non-family member who has knowledge of the work performed.
Company Name: _____________________________________
Street Address: ______________________________________
City/State/Zip: _______________________________________
Phone Number: ______________________________________
Signature: __________________________________________
Title: ______________________________________________

Return Completed Form to:
Western Technical College
400 Seventh St. N., P.O. Box 908
La Crosse, WI 54602-0908
Fax#: 608-789-6255
Contact Information:
Jackie Kettner-Sieber
Phone: 608-789-6233

Date: ______________________________________________