W  I  FACETS  
Family Assistance Center for Education, Training and Support, Inc.
2714 N. Dr. Martin Luther King Drive ◆ Milwaukee, WI ◆ 53212
(414) 374-4645 ◆ 877-374-0511 ◆ FAX (414) 374-4655 ◆ TDD (414) 374-4635

CRIMINAL BACKGROUND CHECK FORM

FOR PROSPECTIVE WI FACETS EMPLOYEES, INDEPENDENT CONTRACTORS,
CONSULTANTS AND VOLUNTEERS
(please print)
NAME: __________________________________________________________
First Middle Last Maiden Name
OTHER NAMES BY WHICH YOU ARE KNOWN : ________________________

DATE OF BIRTH: __________________________________________________

ADDRESS : _______________________________________________________
Street Apt. #
_______________________________________________________
City State Zip
_________________________________________________________________
Please check the appropriate box and, if necessary, fill in the requested information:
 I have a criminal record, and the following are the particulars (offense, date,
location/jurisdiction, circumstance and outcome) of such record:
(Please note: Simply having a criminal conviction does not always mean you will be disqualified from volunteering.
Deference is given to the type and/or severity of the conviction.)

 I do not have a criminal record.

 I have lived outside of Wisconsin within the past 3 years. Please list the States and the
dates that you lived there: ____________ , _____________, ______________

By signing this form, you are agreeing to allow WI FACETS to request a police/criminal
background check on you. You are also acknowledging that the information you have provided
on this form is true and accurate.

_______________________________________ _____________________
Signature Date

To be completed by WI FACETS (date and initial)

Form received on: ________________ Check run on: _________________

Response from Dept of Justice: ________________

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