Background Check Form.docx
DOCX document 40 KB Posted
- Solicitation number
- 2306
- Issued by
- Kenosha County, Kellnersville Village, Wisconsin
About this file
This is a Criminal Background Check Form used by the Kenosha County Sheriff's Department for the Detentions Division Pre-Trial Facility and Kenosha County Detention Center to screen service providers and volunteers. The form requires applicants to provide complete personal information, including name, address, date of birth, contact information, and physical description. Applicants must authorize the Kenosha County Division of Personnel and authorized representatives to obtain criminal records from law enforcement agencies, criminal records bureaus, and the Department of Motor Vehicles. The form identifies the frequency and nature of facility access, categorizing applicants as single-visit or recurring-visit individuals, and captures affiliation information including vendor associations such as KVNA, KUSD, NIJC, contractors, and volunteer programs including Living Free Program, AA/NA Programs, and Chaplaincy services. Emergency contact information is required as part of the application process.
The form serves as authorization for comprehensive background investigations and includes fields for official use documenting approval or denial status, background check dates, orientation scheduling, and clerical tracking. Applicants must acknowledge that submitted information is truthful and complete, with signature and date required to authorize the background check process. The form notes that a photocopy holds the same validity as the original document and includes spaces for exceptions to the blanket authorization. All background check results are tracked internally with documentation of approval status, comments, and completion notifications.
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Other files
| File | Type | Posted |
|---|---|---|
| 2306 Bid Documents.pdf | ||
| Vendor Responsibility Form Construction.pdf | ||
| 2603 Drawings.pdf | ||
| 2306 Addendum 1.pdf | ||
| 2603 Specifications.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 .