Wisconsin Department of Safety and Professional Services Mail To: P.O. Box 8935 FAX #: Phone #: 1400 E. Washington Avenue Madison, WI 53703 E-Mail: web@dsps.wi.gov Website: http://dsps.wi.gov Madison, WI 53708-8935 (608) 261-7083 (608) 266-2112 CONVICTIONS AND PENDING CHARGES If you have been convicted of a crime or have criminal charges pending against you, complete this form and return it with your application. A $8.00 fee is required in addition to your original application fees. This form cannot be faxed. The Fair Employment Act (sections 111.31-111.395, Wis. Stats.) prohibits employment discrimination on the basis of conviction record or arrest record unless the circumstances of the conviction or arrest substantially relate to the circumstances of the particular job or licensed activity. The information requested on this form will be used to determine whether your application should be granted, approved with limitations, or denied. The information you provide on this form may be verified against criminal information records. Omission of information on this form will be considered a false statement on an application. Profession you are applying for: _______________________________________________________________________ Last Name First Name MI Former / Maiden Name(s) Your Street Address (number, street, city, state, zip) Mail To Address (if different) Date of Birth Social Security Number ___________ ___________ month day Ethnic/gender information is required to check criminal information records. ____________ _______________________________________________________ Information helps us identify your record, but is voluntary. It is not available to the public. year Sex: M F Ethnic: White, not of Hispanic origin Black, not of Hispanic origin Hispanic American Indian or Alaskan Asian or Pacific Islander Other 1. List all other names used: _______________________________________________________________________ 2. List all felonies, misdemeanors, and other violations of federal, state or local law or municipal ordinance of which you have ever been convicted, in this state or any other, whether the conviction resulted from a plea of no contest or a guilty plea or verdict. For each, list the date and location of the conviction. Please include all convictions that involved alcohol or other drug use, including convictions for operating while intoxicated. It is your responsibility to submit certified copies of the police report or criminal complaint, judgment of conviction and sentencing, and verification of your compliance with all terms of each sentence, including chemical dependency assessments if ordered by the court. If the conviction is old and records have been destroyed, you must submit a written description of each offense, along with an explanation of the penalties imposed and verification that you completed all requirements. OFFENSE DATE CITY/STATE __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Attach additional sheet(s) if necessary. #2252 (Rev. 9/11) Ch. 111, Stats. Page 1 of 2 Committed to Equal Opportunity in Employment and Licensing American LegalNet, Inc. www.FormsWorkFlow.com Wisconsin Department of Safety and Professional Services 3. Have you ever been sentenced by a court to participate in an alcohol or other drug assessment, treatment or counseling program? YES NO MO/YR COMPLETED _________________ Did you successfully complete the program? _________________ Please attach the certificate of completion/discharge summary. (Check all that apply) 4. Have you ever been sentenced to: YES NO MO/YR COMPLETED Probation Parole Ordered to pay restitution _________________ _________________ _________________ Did you successfully complete one of the above as ordered by the court? _________________ If you are currently on probation or parole, you must request your probation/parole officer to send a letter describing your current probation/parole requirements and your compliance with supervision. 5. List all felonies, misdemeanors, or other violations of federal, state or local law or municipal ordinance for which you have been arrested and which are pending against you. Submit a copy of the police report/criminal complaint for each of the following pending charges. PENDING CHARGE DATE OF ARREST LOCATION OF ARREST (city/state) __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Comments you wish to make regarding your convictions or pending charges. Attach another sheet if necessary. __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ AFFIDAVIT OF APPLICANT I state that I am the person referred to in this document and that all the information which I provided above is true in every respect. I understand that false or forged statements made in this document in connection with my application for a credential, or failing to provide relevant information, may be grounds for denial of the application, revocation of the credential granted to me, or criminal prosecution. This document must be signed before a notary public. ____________________________________________________ Signature ______________________________________ Date Signed and sworn before me this __________________ day of ____________________________ , 20 ____________ . ____________________________________________________ Signature of Notary Public My commission (is permanent) __________ ______________________________________ Date expires ________________________ . SEAL Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com