Form Doa-15506 - Applicant Consent For Background Check Page 3
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3Do you have criminal charges pending against you? Yes No
Have you been convicted of any crime anywhere, including in federal, state, local, military and tribal courts? Yes
No
If you answered “Yes” to any of the above questions, please indicate: (Attach additional pages if necessary to include
the same information for each pending charge or convicted crime).
The nature of the offense
Date of the offense
Date of conviction
County and State or territory where criminal charges(s) is/are pending against you.
Name and location of court
Please discuss the details of the incident and the disposition/outcome (sentence, fine, probation, Huber, suspension
etc.).
Notice: By my signature below I hereby authorize and consent to the State of Wisconsin’s procurement of such a report.
This information will be retained in your application file which is confidential. Wisconsin’s Fair Employment Law, s.
111.31-111.395, Wis. Stats., prohibits discrimination because of a criminal record or pending charge: however, it is not
discrimination to decline to hire a person based on the person’s arrest or conviction record if the arrest or conviction is
substantially related to the circumstances of the particular job. Failure of any applicant (current or potential employee)
to disclose any requested information, including but not limited to: criminal or ordinance violations, convictions, fines,
forfeitures, pending charges (including traffic and DNR charges) or expunged offenses, will make you ineligible. This
includes all adult fines and/or convictions regardless of how many years have elapsed.
I affirm that all the information on this document is true and complete to the best of my knowledge and I understand
that any falsification or omission of information will disqualify me for this position. I authorize the [insert Agency Name]
to conduct a background check and verify the information provided above and to procure a consumer credit report if
applicable.
APPLICANT SIGNATURE
DATE SIGNED
HUMAN RESOURCES USE ONLY
Processed by:
Date Processed:
Requested by:
Decision
Eligible
Not Eligible
Distribution: Original – HR File
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