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Wisconsin Department of Safety and Professional Services (Wisconsin)

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Wisconsin Department of Safety and Professional Services
Mail To: P.O. Box 8935 Office Location: 4822 Madison Yards Way
Madison, WI 53708-8935 Madison, WI 53705
FAX #: (608) 251-3036 E-Mail: dsps@wisconsin.gov
Phone #: (608) 266-2112 Website: http://dsps.wi.gov
DIVISION OF PROFESSIONAL CREDENTIAL PROCESSING
AUTHORIZATION FOR RELEASE OF FBI INFORMATION
(For official use only, not to be released to unauthorized persons)
I hereby empower any employee of the Department of Safety and Professional Services to obtain through the Wisconsin
Department of Justice, a copy of any arrest record maintained by the Federal Bureau of Investigation associated to me pursuant to
a search based on a submitted set of fingerprints within one year of the date of this Form (#2687).
I also understand that federal law prohibits the sharing of this information with anyone other than an employee of the organization
granted permission by this release.
If we receive a criminal history report, you will have the opportunity to complete, or challenge the accuracy of the information
contained in the FBI identification record. The procedures for obtaining a change, correction or updating of the FBI identification
record are set forth in 28 CFR 16.34. We would not deny the license or employment based on the information in the record until
you have been afforded a reasonable time to correct or complete the record or have declined to do so.
PRIVACY STATEMENT
Authority: The FBI’s acquisition, preservation, and exchange of information requested by this form is generally authorized under
28 U.S.C. 534. Depending on the nature of your application, supplemental authorities include numerous Federal statutes,
hundreds of State statutes pursuant to Pub.L. 92-544, Presidential executive orders, regulations, and/or orders of the Attorney
General of the United States, or other authorized authorities. Examples include but are not limited to 5 U.S.C. 9101;
Pub.L. 94-29; Pub.L. 101-604; and Executive Orders 10450 and 12968. Providing the requested information is voluntary;
however, failure to furnish the information may affect timely completion or approval of your application.
Social Security Number (SSN): Your SSN is needed to keep records accurate because other people may have the same name and
birth date. Pursuant to the Federal Privacy Act of 1974 (5 USC 552a), the requesting agency is responsible for informing you
whether disclosure is mandatory or voluntary, by what statutory or other authority your SSN is solicited, and what uses will be
made of it. Executive Order 9397 also asks Federal agencies to use this number to help identify individuals in agency records.
Principal Purpose: Certain determinations, such as employment, security, licensing, and adoption, may be predicated on
fingerprint-based checks. Your fingerprints and other information contained on (and along with) this Form (#2687) may be
submitted to the requesting agency, the agency conducting the application investigation, and/or FBI for the purpose of comparing
the submitted information to available records in order to identify other information that may be pertinent to the application.
During the processing of this application, and for as long hereafter as may be relevant to the activity for which this application is
being submitted, the FBI may disclose any potentially pertinent information to the requesting agency and/or to the agency
conducting the investigation. The FBI may also retain the submitted information in the FBI’s permanent collection of fingerprints
and related information, where it will be subject to comparisons against other submissions received by the FBI. Depending on the
nature of your application, the requesting agency and/or the agency conducting the application investigation may also retain the
fingerprints and other submitted information for other authorized purposes of such agency(ies).
Routine Uses: The fingerprints and information reported on this Form (#2687) may be disclosed pursuant to your consent, and
may also be disclosed by the FBI without your consent as permitted by the Federal Privacy Act of 1974 (5 USC 552a(b)) and all
applicable routine uses as may be published at any time in the Federal Register, including the routine uses for the FBI Fingerprint
Identification Records System (Justice/FBI-009) and the FBI’s Blanket Routine Uses (Justice/FBI-BRU). Routine uses include,
but are not limited to, disclosures to: appropriate governmental authorities responsible for civil or criminal law enforcement,
counterintelligence, national security or public safety matters to which the information may be relevant; to State and local
governmental agencies and non-governmental entities for application processing as authorized by Federal and State legislation,
executive order, or regulation, including employment, security, licensing, and adoption checks; and as otherwise authorized by
law, treaty, executive order, regulation, or other lawful authority. If other agencies are involved in processing this application,
they may have additional routine uses.
#2687 (Rev. 6/2021)
Wis. Stat. § 440.26 i
Committed to Equal Opportunity in Employment and Licensing
Wisconsin Department of Safety and Professional Services
Additional Information: The requesting agency and/or the agency conducting the application investigation will provide you
additional information pertinent to the specific circumstances of this application, which may include identification of other authorities,
purposes, uses, and consequences of not providing requested information. In addition, any such agency in the Federal Executive
Branch has also published notice in the Federal Register describing any system(s) of records in which that agency may also maintain
your records, including the authorities, purposes, and routine uses for the system(s).
RECORD COMPLETENESS OR ACCURACY CHALLENGE NOTICE
FBI Record: This record is subject to the following use and dissemination restrictions:
Under provisions set forth in Title 28, Code of Federal Regulations (CFR), Section 50.12, both governmental and nongovernmental
entities authorized to submit fingerprints and receive FBI identification records must notify the individuals fingerprinted that the
fingerprints will be used to check the criminal history records of the FBI. Identification Records obtained from the FBI may be used
solely for the purpose requested and may not be disseminated outside the receiving department, related agency, or other authorized
entity.
The official making the determination of suitability for licensing or employment shall provide the applicant the opportunity to
complete, or challenge the accuracy of, the information contained in the FBI identification record. The deciding official should not
deny the license of employment based on the information in the record until the applicant has been afforded a reasonable time to
correct or complete the information or has declined to do so.
An individual should be presumed not guilty of any charge/arrest for which there is no final disposition stated on the record or
otherwise determined. If the applicant wishes to correct the record as is appears in the FBI’s CJIS Division Records System, the
applicant should be advised that the procedures to change, correct, or update the record are set forth in Title 28, CFR, Section 16.34.
The CJIS Division is not the source of the data appearing on identification records. All data is obtained from fingerprint
submissions or related identification forms submitted to the FBI by local, state, and federal agencies. As a result, the
responsibility for authentication and correction of such data rests upon the contributing agency (i.e., police department,
county court, etc.). Please contact this agency or the central repository in the state where the arrest occurred to request a
change, correction, or update. The FBI is not authorized to modify the record without written notification from the
appropriate criminal justice agency.
Wisconsin Record: Subject to Wisconsin Statutes 111.33 to 111.36, Section 111.321 of the Wisconsin Statutes prohibits act of
employment discrimination based on arrest and conviction records. Applicants should be notified of their right to challenge the
accuracy and completeness of any information contained in a criminal record before any final determination is made. Challenges
should be submitted to the Crime Information Bureau on Form DJ-LE-247 and may include a request for fingerprint comparison.
Form DJ-LE-247 and information on the Wisconsin challenge process may be found online at
https://www.doj.state.wi.us/dles/cib/background-check-criminal-history-information.
Other State’s Record: Contact the state from which the record originates to inquire about their challenge process.
#2687 (Rev. 6/2021)
Wis. Stat. § 440.26 ii
Committed to Equal Opportunity in Employment and Licensing
Wisconsin Department of Safety and Professional Services
Mail To: P.O. Box 8935 Office Location: 4822 Madison Yards Way
Madison, WI 53708-8935 Madison, WI 53705
FAX #: (608) 251-3036 E-Mail: dsps@wisconsin.gov
Phone #: (608) 266-2112 Website: http://dsps.wi.gov
DIVISION OF PROFESSIONAL CREDENTIAL PROCESSING
AUTHORIZATION FOR RELEASE OF FBI INFORMATION
Instructions: Complete all requested information for type of license applying for and submit Page 1 only. Pages i and ii are for
applicant’s information only.
Type of License Applying For:
Private Security Person/Private Detective/Firearms Certifier Juvenile Martial Arts Instructor
Licensed/Certified Real Estate Appraiser
RN/LPN Multistate License
Medical Licensing Compact
Physical Therapist/Physical Therapist Assistant Compact
NOTE: ALL APPLICANTS FOR THE PROFESSIONS LISTED ABOVE MUST ATTACH A RECENT PHOTOGRAPH
(head and shoulders only).
Last Name
First Name
MI
Race/Ethnicity/Sex information is required for criminal background check.
RACE/ETHNICITY:
White American Indian or Alaskan Native Hispanic
Black
Asian or Pacific Islander
Other
SEX: Male Female
Wisconsin License Number (if applicable)
Address (street, city, state, zip code)
Signature (Print and Sign Form)
/ /
For Wholesale Distributor of Prescription Drugs: Please note: This Form (#2687) is required even if the applicant is a National
Association of Boards of Pharmacy (NABP) Accredited Drug Distributor.
Applicant’s DBA Name
Facility’s Address (street, city, state, zip code)
Designated Representative’s Name
Designated Representative’s Signature (Print and Sign Form)
/ /
NOTE: RECENT PHOTOGRAPH OF THE DESIGNATED REPRESENTATIVE MUST BE ATTACHED TO FORM 2812.
(See Form 2812 for details.)
#2687 (Rev. 6/2021)
Wis. Stat. § 440.26 Page 1 of 1
Committed to Equal Opportunity in Employment and Licensing
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Completed 20 January 2022

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