Background Check Form.docx
DOCX document 40 KB Posted
- Attached to
- Kenosha County Pre-Trial Facility HVAC Improvements - Note this bid has been cancelled as of 12/15/2025
- Solicitation number
- 2522
- Issued by
- Kenosha County, Wisconsin
About this file
This is a criminal background check form issued by the Kenosha County Sheriff's Department Detentions Division for service providers and volunteers seeking access to the Pre-Trial Facility and Kenosha County Detention Center. The form collects applicant information including personal identification, contact details, physical description, and previous states of residence for the past five years. Applicants must authorize the Kenosha County Division of Personnel to obtain criminal records from law enforcement agencies, criminal records bureaus, and Department of Motor Vehicles records. The form requires applicants to specify the duration and frequency of facility visits, their affiliation type (including contractor, volunteer, or program-specific roles such as Living Free Program, AA/NA Programs, or Chaplaincy), and emergency contact information. Background check approval or denial is determined by the Sheriff's Department and documented in the official section of the form, with tracking mechanisms for background check completion, orientation scheduling, and clerical processing.
The form serves as a blanket authorization for release allowing exceptions at the applicant's discretion and applies to all individuals requiring facility access regardless of position or affiliation status. Applicants must provide truthful and complete information, with submission of the form constituting authorization for background investigation including criminal history review. The form releases all institutions and personnel from liability related to background check processes and information obtained during the employment or volunteer screening process. A photocopy of the executed release is considered valid as the original, and applicants must sign and date the form before submission to the Sheriff's Department.
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Other files
| File | Type | Posted |
|---|---|---|
| 2522 Specifications.pdf | ||
| 2522 Bid Documents.pdf | ||
| 2522 Addendum 1.pdf | ||
| 2522 Drawings.pdf | ||
| Vendor Responsibility Form Construction.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 .