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
Charge(s):
Location of Offense:
Date of Conviction: / /
Sentence:
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: / /
Explanation:
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.
