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                                                                                                     Division of Corporate and
   Chapter 202, Wis. Stats.             STATE OF WISCONSIN
                                                                                                         Consumer Services
        Subchapter I
                                 Department of Financial Institutions
            E-Mail:                                                                                      Mailing Address:
DFICharitableOrgs@wi.gov                                                                                       PO Box 7879
Telephone: (608) 267-1711                                                                            Madison, WI 53707-7879
   Fax: (608) 267-6813                                                                                   Courier Address:
                                                                                                     4822 Madison Yards Way
                                                                                                                  North Tower
        www.wdfi.org         CONVICTIONS AND PENDING CHARGES                                             Madison, WI 53705

Purpose:     If you have been convicted of a crime or have criminal charges pending against you, complete this form and return it
with your application.  This form should only be submitted with registration applications for charitable organizations, professional
fundraisers, fundraising counsels, professional employer organizations and professional employer groups.

1. Provide the following personal information.

   Last Name:                                           First Name:                     MI Former/Maiden Name(s):

   Street Address:                                                                         P.O. Box:

   City:                                                              State:                         Zip:

   Date of Birth:                                                     Social Security Number:

   Name of Charity, Fundraiser, or PEO:

2. List all other names used.

3. List all felonies, misdemeanors, and other violations of federal, state or local law or municipal ordinance of which you have
   ever been convicted, in this state or any other, whether the conviction resulted from a plea of no contest or a guilty plea or
   verdict.  For each, list the date and location of the conviction.  Please include all convictions that involved alcohol and or other
   drug use, including convictions for operating while intoxicated.  During the department’s review of the application for
   registration, you may be asked to submit the following:
        • copies of the police report or criminal complaint
        • criminal history report
        • judgment of conviction and sentencing
        • verification of compliance with all terms of each sentence, including chemical dependency assessments (if ordered by
          the court)
        • information pertaining to probation or parole requirements and compliance
        • personal statement describing each offense along with an explanation of the penalties imposed and verification that you
          completed all requirements.

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4. List all felonies, misdemeanors, or other violations of federal, state or local law or municipal ordinance for which you have
   been arrested and which are pending against you.  For each, list the date of arrest and location (city/state).  Submit a copy
   of the police report/criminal complaint for each pending charge.

5. Provide any comments you wish to make regarding your convictions or pending charges.  Additional pages may be attached.

AFFIDAVIT
I state that I am the person referred to in this document and that all information which I provided above is true in every respect.
I understand that false or forged statements made in this document in connection with my application for a credential, or failing
to provide relevant information, may be grounds for denial of the application, revocation of the credential granted to me, or
criminal prosecution.

______________________________________________________________________________________________________
Applicant Signature                                                                                       Date

SUBSCRIBED AND SWORN TO BEFORE ME
THIS________ DAY OF_________________,_______

________________________________________________
(Notary Public)

My Commission Expires: __________________________

RETURN MATERIALS TO:  Department of Financial Institutions, Division of Corporate and Consumer Services.
Mailing Address:                                         Street Address:
PO Box 7879                                              4822 Madison Yards Way, North Tower
Madison, Wisconsin 53707-7879                            Madison, Wisconsin 53705
The Fair Employment Act (sections 111.31-111.395, Wis. Stats.) prohibits employment discrimination on the basis of conviction record or
arrest record unless the circumstances of the conviction or arrest substantially relate to the circumstances of the particular job or licensed
activity.  The information requested on this form will be used to determine whether your application should be granted, approved with
limitations, or denied.  The information you provide on this form may be verified against criminal information records.  Omission of
information on this form will be considered a false statement on an application.
Notice:  Completion of this form is required under Section 202.02, Wisconsin Statutes.  Failure to comply may result in further action by our
Department.   Personal information you provide may be used for secondary purposes.
This document can be made available in alternate formats upon request to qualifying individuals with disabilities.

DFI/DCCS/2252 (R 03/201 )8                              CONVICTIONS & PENDING CHARGES                                                    Page 2 of 3

                                                        FREQUENTLY ASKED QUESTIONS

1. If I was named in a trial but not convicted, do I need to report or submit anything?
   You might want to send in a court document stating either that the charges were dismissed or you were acquitted.  If
   you entered into a deferred prosecution agreement, you might want to submit a copy of the agreement and verification
   that you have complied with all terms and conditions of the agreement.

2. What do I do if records are no longer available due to the length of time passed since the conviction?
   If convictions are old or records are no longer available, please include a personal statement (as described below)
   describing each offense listed on the #2252 along with an explanation of the penalties imposed and verification that you
   completed all requirements.

3. Do I need to report or submit anything about minor traffic violations, i.e. a speeding ticket?
   There is no need to disclose minor traffic violations.

4. How can I find out if I am excluded from getting a license due to a conviction?
   Each profession is regulated by its respective statutes and rules.  Please refer to the respective statutes and rules of the
   profession for which you are applying to determine whether your conviction records are substantially related to the
   practice of the profession.  We are unable to determine prior to full review whether an applicant will or will not be
   issued a license based on the conviction records.

5. How long does it take to review these documents?
   The time period for conviction review varies depending on when all documentation is received and whether it needs to
   be reviewed by supervisory staff.

6. What needs to be in the personal statement?
   A personal statement should describe each offense listed on the #2252 along with an explanation of the penalties
   imposed and verification that you completed all requirements.  You might also include any information about changes
   in your life (since the time of your last conviction) that you would like the division to consider during the review.

7. Do I need to hire a lawyer?
   It is your decision as to whether you need to hire an attorney.  If you would like a legal opinion you might want to hire
   a private attorney as the Department of Financial Institutions does not provide legal advice to applicants.

DFI/DCCS/2252 (R 03/201 )8                              CONVICTIONS & PENDING CHARGES                                                    Page 3 of 3