Office of the Secretary of State
Department of Personnel
Application Background Disclosure Form
(The following information should be typed or LEGIBLY printed in INK.)
Name: _________________________________________ Social Security Number: - -
If you answered “YES” to question #1 and/or #2 on the front page of the Secretary of State Employment Application, you may use
this form to provide your explanation(s).
If you are obligated to answer “YES” to one or both of these questions, your explanation(s) must
be provided with every application
submitted to this office.
Your application(s) cannot be processed until all the information requested below has been provided. Respond for all related situa-
tions. You may attach additional pages as necessary.
Criminal Conviction
Location of Offense:
Date of Conviction: / /
Explanation: (Include nature of crime and your involvement and actions.)
Employment Discharge
Name of Employer:
Address of Employer:
Dates of Employment: From / / To / /
Job Title:
Date of Action: / /
Printed by authority of the State of Illinois. March 2021 — 2M — Per D 199.5
Return Background Disclosure Form along with the Employment Application to:
Secretary of State, Department of Personnel, 196 Howlett Bldg., Springfield, IL 62756; or 17 N. State St., Ste. 1300, Chicago, IL 60602.