Form Doa-15506 - Applicant Consent For Background Check
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3STATE OF WISCONSIN
DEPARTMENT OF ADMINISTRATION
DIVISION OF PERSONNEL MANAGEMENT
DOA-15506 (C06/2016)
APPLICANT CONSENT FOR BACKGROUND CHECK
How are you protected?
Indicating you have an arrest or conviction record does not automatically disqualify you from consideration for a job.
Wisconsin’s Fair Employment Law, s. 111.31-111.395, Wis. Stats., prohibits discrimination based on an arrest or conviction
record. It is not discrimination, however, to decline to hire a person based on the person’s arrest record, if there is a
pending charge, or conviction record – deemed substantially related to the circumstances of the particular job.
Information gathered in the Criminal Background Check will enable us to determine if the arrest or conviction record is
substantially related to the job.
The information you provide on this form will be retained in a confidential manner.
What do you need to do now?
Applicants are required to complete, sign and return the attached form in order to remain under consideration for this
position. [Insert agency specific instructions for example: Please complete the form, place it in a sealed envelope and
leave it with the interview coordinator or supervisor before you leave after your interview.]
Completed and signed forms may also be returned
By Fax
By E-Mail
By Mail
This form must be completed and returned within 2 business days of the date of your interview in order for you to continue
to be considered for this position.
Definition of terms used on this form:
Arrest Record: “Includes, but is not limited to, information indicating that an individual has been questioned, apprehended,
taken into custody or detention, held for investigation, arrested, charged with, indicted or tried for any felony, misdemeanor
or other offense pursuant to any law enforcement or military authority.” s.
111.32(1), Wis. Stats.
Conviction Record: “Includes, but is not limited to, information indicating that an individual has been convicted of any
felony, misdemeanor or other offense, has been adjudicated delinquent, has been less than honorably discharged, or has
been placed on probation, fined, imprisoned, placed on extended supervision or paroled pursuant to any law enforcement
or military authority.” s. 111.32(3), Wis. Stats.
Criminal Charge: A criminal complaint, information, or indictment filed in a state, federal, tribal or international court of law.
Prior to completing this form, it may be beneficial to review the Wisconsin Circuit Court records pertaining to you
at
and obtain a copy of your driver license abstract at
Please remember not all fines/convictions may appear on
the Wisconsin Circuit Court site. To obtain your complete record visit
Failure to report a fine and/or conviction may result in not being considered for this position.
Questions about this form may be directed to [Insert contact information]
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