Background Check Form.docx
DOCX document 40 KB Posted
- Attached to
- Operational Study for Corrections
- Solicitation number
- 2612
- Issued by
- Kenosha County, Wisconsin
About this file
This is a Criminal Background Check Form used by the Kenosha County Sheriff's Department, Detentions Division for the Pre-Trial Facility and Kenosha County Detention Center to screen service providers and volunteers. The form requires applicants to provide complete and truthful personal information including name, address, date of birth, contact information, physical description, and driver's license details. Applicants must authorize the Kenosha County Division of Personnel and other authorized representatives to obtain criminal history records from law enforcement agencies, criminal records bureaus, and the Department of Motor Vehicles. The form requests applicants to specify the frequency and nature of their facility access (single visit or recurring), their affiliation type (contractor, volunteer, or program-based such as Living Free Program, AA/NA Programs, or Chaplaincy), and emergency contact information. The form includes a tracking section for official use only, documenting background check dates, approval or denial status, and completion of orientation and notification processes.
The background check authorization serves as a blanket release form with provision for applicants to note exceptions to the inquiry scope. Approval or denial decisions are documented by an authorized signature, and applicants may submit photocopies of the completed form as valid originals. This document represents a standard administrative screening tool for facilities operated by the Kenosha County Sheriff's Office to ensure the safety and security of detention facilities located at 927 54th Street and 4777 88th Avenue in Kenosha, Wisconsin.
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Other files
| File | Type | Posted |
|---|---|---|
| 2612 RFP Documents.pdf | ||
| 2612 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 .