Transcription of F-82064 (01/2022) Page 1 of 2 BACKGROUND INFORMATION ...
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F-82064 (01/2022) Page 1 of 2 BACKGROUND INFORMATION ...
DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-82064 (0 7/2018) STATE OF WISCONSIN Wis. Stat. Wis. Admin. Code DHS (4) Page 1 of 4 BACKGROUND INFORMATION DISCLOSURE (BID) PENALTY: Knowingly providing false INFORMATION or omitting INFORMATION may result in a forfeiture of up to $1,000 and other sanctions as provided in Wis. Admin. Code DHS (4). Completion of this form is required under the provisions of Wis. Stat. Failure to comply may result in a denial or revocation of your license, certification, or registration, or denial or termination of your employment or contract. Refer to DQA form F-82064A, BID Instructions, for additional INFORMATION . Providing your social security number is voluntary; however, your social security number is one of the unique identifiers used to prevent incorrect matches. PRINT OR TYPE YOUR ANSWERS.
or by entities requesting approval for an individual to reside in entity facilities as a . non-client resident. Applicants for . entity operator approval. or for a . non-client resident . background check must request an . ... Have you resided outside of Wisconsin in the last three (3) years? If . Yes, list each state and the dates you resided ...
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