2421 Exhibit C Background Check Application.docx

Revision 03/2021 This is a printer friendly packet available for printing and or to submit electronically RFP #2421, Medical Services for Corrections Exhibit C Please complete this application for the Pre-Proposal Conference and Tours.

Upon completion submit for approval. Feel free to email it to Matt.Fleming@kenoshacountywi.gov or print it out and mail it back to us at:

Matthew Fleming County of Kenosha Purchasing Division 1010 56th Street, Second Floor Kenosha, WI 53140

Once the background check has been completed and approved, and you have received your orientation training, your name will be added to the approved roster for volunteers or service providers. You cannot enter either facility without your name being on this approved list and until you have received your orientation. Your approved security clearance may expire after one year of inactivity and may require renewal by submitting a new application. If any information changes throughout the year, volunteers are required to immediately report those changes. This includes notification to the facility of any new criminal charges or active warrants. You are subject to a status review, and a new background check every three years. At the culmination of the application and orientation processes, you will be required to sign a statement indicating that you understand the training that you have received, along with a liability notice and release.

Kenosha County Sheriff’s Department – Detentions Division Pre-Trial Facility & Kenosha County Detention Center Service Provider / Volunteer Information Form Criminal Background Check

Information provided on this form must be truthful and complete.

Applicant Information:

Last Name

First Name

Middle

Address

City

Date of Birth

Maiden Name/ Alias/ Other names

Primary Phone Number

Secondary Phone Number

Previous States of Residence for the Last Five Years.

Driver’s License # and State of Issue

Email Address

Physical Description:

Sex

Race

Eye Color

Height

Weight

I hereby empower any employee of the Kenosha County Division of Personnel, or other authorized representative bearing this release, to obtain information and records relevant to my application from any or all of the following sources:

I hereby release any individual or institution, including its officers, employees, or related personnel, both individually and collectively, from any and all liability for damages of whatever kind which may at any time result to me, my heirs, my family, or my associates because of compliance with or any attempt to comply with this authorization and using the information obtained as part of the employment process.

This document is a blanket Authorization for Release form. The duties and qualifications of the position applied for will determine which background inquiries are made and what background information is considered to be relevant to that position.

Exceptions to this blanket authorization:

1. ______________________________________________________________________

2. ______________________________________________________________________

Duration:

Please check one that applies

Multiple – recurring visits |_|

Affiliation:

KUSD: |_| NIJC: |_| Contractor: |_| Company Name:

Who should be notified in case of emergency?

Name:

By submitting this application, I am authorizing the Kenosha County Sheriff’s Department to conduct a background check to include a criminal history.

Applicant Signature: Date:

A photocopy of this release is as valid as the original.

FOR OFFICAL USE ONLY DO NOT WRITE IN BOX BELOW

Background Check Date:

Comments:

Approval Signature: _______________________________________________________

Tracking:

Background ____ Orientation Scheduled ___ Notification of Completion ___ Clerical for Scanning ___