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Fillable Printable April 2017 Ap-731 Background Disclosure Form Fill-In

Fillable Printable April 2017 Ap-731 Background Disclosure Form Fill-In

April 2017 Ap-731 Background Disclosure Form Fill-In

April 2017 Ap-731 Background Disclosure Form Fill-In

Background Disclosure Form
Applicants are required to provide information about any conviction records or any pending charges. Wisconsin’s Fair
Employment Law, s.111.31-111.395, Wis. Stats., prohibits discrimination because of an arrest or conviction record or
pending charge; however, it is not discrimination to decline to hire a person based on the person’s arrest or conviction
record if the conviction or pending charge is substantially related to the circumstances of the particular job.
Failure of any applicant (current or potential employee) to disclose any requested information, including but not limited to:
criminal or ordinance violations, convictions, nes, forfeitures and pending charges, will disqualify you for this position.
This includes all nes and/or convictions (including, trafc, municipal and DNR charges) regardless of how many years
have elapsed.
Name (Last)
( )
Home Address
Day Phone Number
( )
List Former Name(s), Aliases (first, middle, last) (including maiden name)
Date of Birth (mm/dd/yyyy)
Social Security Number
CityStateZip Code
FirstM.I.
Evening Phone NumberEmail Address
//
Applicants are required to complete, sign and return the attached form in order to remain under consideration for this
position. Prior to completing this form, it may be benecial to review the Wisconsin Circuit Court records pertaining to you
at //wcca.wicourts.gov. Please remember not all nes/convictions may appear on the Wisconsin Circuit Court site. To
obtain your complete record visit the Department of Justice site at //www.doj.state.wi.us/dles/cib/background-check-
criminal-history-information.
Failure to report a violation, conviction, ne/forfeiture, or pending charge will result in you not being considered
for this position.
AP-731 (R. 4-17)Wisconsin Department of Revenue
(Continued on next page)
1. Do you have any charges pending against you?....................................... Yes No
2. Have you ever plead guilty or no contest to a charge or have any convictions anywhere, including
in federal, state, local or municipality, military and tribal courts? ........................... Yes No
If you answered “Yes” to any of the above questions, please provide the information requested below. (Attach
additional pages if necessary).
Date of
Offense
Name / Location
of Court
Disposition
of Outcome
Details of Charges / Incident
3. Have you failed to le your Wisconsin individual income and any applicable business tax returns
on time? ..................................................................... Yes No
If yes, provide tax year(s):
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How are you protected?
Indicating you have an arrest or conviction record does not automatically disqualify you from consideration for a job.
Wisconsin’s Fair Employment Law, s. 111.31-111.395, Wis. Stats., prohibits discrimination based on an arrest or conviction
record. It is not discrimination, however, to decline to hire a person based on the person’s arrest record, a pending charge,
or conviction record if deemed substantially related to the circumstances of the particular job. Information gathered in the
Criminal Background Check will enable us to determine if the arrest or conviction record is substantially related to the job.
The information you provide on this form will be retained in a condential manner.
Denition of terms used on this form:
Arrest Record: “Includes, but is not limited to, information indicating that an individual has been questioned, apprehended,
taken into custody or detention, held for investigation, arrested, charged with, indicted or tried for any felony, misdemeanor
or other offense pursuant to any law enforcement or military authority.” s. 111.32(1), Wis. Stats.
Conviction Record: “Includes, but is not limited to, information indicating that an individual has been convicted of any
felony, misdemeanor or other offense, has been adjudicated delinquent, has been less than honorably discharged, or has
been placed on probation, ned, imprisoned, placed on extended supervision or paroled pursuant to any law enforcement
or military authority.” s. 111.32(3), Wis. Stats.
Criminal Charge:A criminal complaint, information, or indictment led in a state, federal, tribal or international court of law.
Please complete the form, place in an envelope and seal it. Write your name on the envelope and the title of the position
you are applying for and bring to the interview if instructed, or mail the completed form to the following address:
Wisconsin Department of Revenue
Attn: Human Resources MS 6-261
PO Box 8931
Madison WI 53708-8931
Questions about this form may be directed to DORHumanResources@wisconsin.gov.
AP-731 (R. 4-17)
Wisconsin Department of Revenue
-2-
FOR HR USE ONLY
SupervisorRequested by
Processed by / Date
Position
Non Filer Check
Pass
Fail
Hiring Decision
Eligible
Not Eligible
Notes:
Background Check
Pass
Fail
I state that all the information on this form is true and complete to the best of my knowledge and I understand that any falsication or
omission of information related to any convictions or pending charges will disqualify me for this position. By signing this form, I authorize
the Department to conduct a background check and verify the information provided above.
Applicant Signature Date (mm/dd/yyyy)
//
4. Excluding your current address, please list address locations for the last 7 years. (Attach additional pages if necessary.)
CityState
Zip Code
Dates
From
To
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