Background Check Form.docx
DOCX document 40 KB Posted
- Solicitation number
- 2519
- Issued by
- Kenosha County, Kellnersville Village, Wisconsin
About this file
This document is a Background Check Form for the Kenosha County Sheriff's Department's Detentions Division Pre-Trial Facility and Kenosha County Detention Center, designed to collect comprehensive personal information and authorize criminal background checks for service providers and volunteers. The form is applicable to individuals associated with various organizations and programs, including KVNA, KUSD, NIJC, contractors, Living Free Program, AA/NA Programs, Chaplaincy, and other potential affiliates seeking access to the detention facilities. The form requires detailed personal information such as name, address, date of birth, physical description, previous states of residence, and contact details.
The background check authorization allows Kenosha County personnel to obtain information from law enforcement agencies, criminal record bureaus, and Department of Motor Vehicles. Applicants must specify the frequency of their visits (single or multiple/recurring) and provide emergency contact information. The form includes an official section for tracking background check status, with options for approval or denial, and requires the applicant's signature acknowledging authorization for the criminal history investigation. The document serves as a standardized method for vetting individuals who will have access to or provide services within the Kenosha County Detention Center, ensuring safety and security protocols are maintained.
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| 2419 Bid Documents.pdf | ||
| Vendor Responsibility Form Construction.pdf | ||
| 2519 Drawings.pdf | ||
| 2519 Specifications.pdf | ||
| 2519 Addendum 1.pdf |
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Text version
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
| State |
| Zip |
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:
| 1. | Any law enforcement agency or criminal records bureau (CIB/NCIC). |
| 2. | Any Department of Motor Vehicles. |
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
| How often will you be in the KCDC? |
| A single one time visit |_| |
Multiple – recurring visits |_|
Affiliation:
KVNA: |_| KUSD: |_| NIJC: |_| Contractor: |_| Company Name:
| Volunteer: | Living Free Program: | |_| | ||||
| AA/NA Programs: | |_| | |||||
| Chaplaincy: | |_| | |||||
| Other: | |_| | describe: |
Who should be notified in case of emergency?
| Name: |
| Phone Number: |
Name:
| Phone Number: |
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:
| Approved: | |_| | |
| Denied: | |_| |
Comments:
Approval Signature: _______________________________________________________
Tracking:
Background ____ Orientation Scheduled ___ Notification of Completion ___ Clerical for Scanning ___
File details come from the government source that posted it. Updated .