Verification-of-Self-Employment
VERIFICATION OF SELF EMPLOYMENT 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) _______________________ To: (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 Email: kettner-sieberj@westerntc.edu Date: ______________________________________________ 7/15
