Form Doa-15506 - Applicant Consent For Background Check Page 2
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3APPLICANT CONSENT FOR BACKGROUND CHECK
HUMAN RESOURCES USE ONLY
Position Type: Permanent
Project
Limited-Term Work Study Volunteer Contractor
Position Number: ________________ Cert Number (optional): _______________ Classification Title: ______________________
Does this position have a fleet requirement? Yes No
In order to be considered for the position you applied for we must complete a Criminal Background Check. As part of
the Criminal Background Check the [insert agency name] may obtain a consumer report that includes, but is not limited
to, creditworthiness or similar characteristics, employment and education verifications, social security verification,
criminal and civil history, reference checks, DMV records, any other public records and any other information bearing on
your credit standing, credit capacity, character, general reputation, personal characteristics and trustworthiness.
Failure to provide all requested information below, including your Social Security Number, will prevent [insert agency
name] from completing the required background check for hiring purposes, and will result in your disqualification from
the hiring process.
Name (Last, First, Middle)
Sex:
Female Male
Date of Birth (Month/Day/Year
Social Security Number
Street Address
City, State, Zip Code
Email Address
Day Phone:
Evening Phone:
Former Name(s)Aliases (First, Middle, Last)
In the top box where it states “Human Resources use only” it asks if this position has a fleet requirement. If the box is
marked as Yes, please fill in the following driver’s license information. If the box is marked no, you do not need to fill in
the driver’s license information and can proceed after this section.
Driver’s License State
Driver’s License Number
Have you always lived in Wisconsin Yes No
If No, provide place(s) of residence (State/County) and time period(s)
Place(s) of residence outside of Wisconsin and time period(s) for the last 7 years. Attach additional pages if needed.
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