Wisconsin Department of Safety and Professional Services 
        Mail To:     P.O. Box 8935                            4822 Madison Yards Way 
                     Madison, WI  53708-8935                  Madison, WI  53705 
        FAX #: (608) 251-3036                                 E-Mail: web@dsps.wi.gov
        Phone #: (608) 266-2112                               Website: http://dsps.wi.gov

                     ADDENDUM TO APPLICATION – BUSINESS ENTITIES 

EMPLOYER IDENTIFICATION NUMBER.  Your employer identification number or your social security 
number if you are a sole proprietorship must be submitted with your application on this form.  If you do not 
have a social security number you must submit a statement under oath or affirmation.  If your social security 
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number or a statement is not provided, your application will be denied. A form for submitting a statement that 
you do not have a social security number is available from the department. 

                  (Please Print) 

 _______________________________________________ 
Business Entity Name                                                                  FEIN 

 __________________________________________________________________________________________________ 
Type of Credential (License) applying for 

The Department may not disclose the employer identification number or social security number collected above 
except to the Department of Children and Families for purposes of administering the child and spousal support 
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program,  to the Department of Revenue for the purpose of determining whether you are liable for delinquent
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taxes,  and to the federal Healthcare Integrity and Protection Data Bank for the purpose of reporting adverse
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actions against health care practitioners.  

DELINQUENT STATE TAXES; DELINQUENT SUPPORT 
All applications for professional credentials are checked to determine whether the applicant is liable for
delinquent state taxes. Under state law, the department must deny your application if you are liable for
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delinquent Wisconsin taxes. If you are liable for delinquent state taxes, pay the delinquent amount before the 
application process is completed. Retain proof that you have satisfied the tax delinquency. If you have any
questions about payment of delinquent taxes, please contact your nearest Department of Revenue office or call 
(608)  251-3036.  An application may be denied or a credential suspended if an applicant or credential holder is
delinquent in paying support or fails to comply with a subpoena or warrant issued by the department of
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workforce development or a county child support agency related to support or paternity proceedings.

EMAIL ADDRESS: 
Do you have an email address?                 Yes         No
If yes, this field is required to receive your application status electronically.  Your email address must be clearly legible 
with the correct case sensitive information. 
EMAIL ADDRESS:      Submit your email address in the spaces provided below or attach a printer copy. 

If no, your checklist will be sent by first class mail. 

___________________ 

#2552 (Rev. 8/11) 
1                                                       4
 Section 440.03 (11m), Wis. Stats.                        Health Insurance Portability and Accountability Act (HIPAA) of 1996 
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 Sections 49.857, and 440.13, Wis. Stats.                 Section 440.14, Wis. Stats. 
3                                                       6 
 Section 440.12, Wis. Stats.                              Section 440.12, Wis. Stats. 

This form is authorized by secs. 440.12 and 440.14, Wis. Stats.  Making a false statement in connection with this application may 
result in revocation or denial. 
                                   Committed to Equal Opportunity in Employment and Licensing