• Background Information Disclosure

  • Completion of this form is required under the provisions of Wis. Stat. § 48.685 and Wis. Admin. Code § DCF 12.03. Pursuant to Wis. Stat. § 48.685, this form must be completed prior to licensure, certification, employment or non-client residency and is only valid for 120 days. Failure to comply may result in a denial or revocation of your license or certification; denial or termination of your employment or contract; or denial or revocation of the license or certification for a child care center location at which you reside. Providing your social security number (SSN) is voluntary; not providing it could result in an information processing delay. Personal information you provide may be used for secondary purposes [Privacy Law, Wis. Stat. §15.04(1)(m)].

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  • SECTION A – ACTS, CRIMES, AND OFFENSES THAT MAY ACT AS A BAR OR RESTRICTION
  • SECTION B – OTHER REQUIRED INFORMATION
  • A “NO” answer to all questions does not guarantee employment, residency, a contract, or regulatory approval.
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  • Should be Empty: