logo DISCLOSURE / RELEASE OF INFORMATION STATEMENT
The responsibility of the Chippewa Falls Area Unified School District to its school children and community necessitates collecting the following information regarding criminal conviction. A conviction record does not prohibit employment. However, failure to accurately complete this form may mean disqualification from consideration for employment or volunterring. Applicants must report any convictions that occur subsequent to the time they initially completed this form. Provide all the information requested within three work days to the Director of Human Resources, Chippewa Falls School District, 140 W Elm St, Chippewa Falls, WI 54729.
Last Name:
 First Name (Legal full first name, no nicknames):
 Middle Initial:
Gender:
Other names used (including maiden name): Dates of Usage:
Street Address:
 City:
 State:
 Zip:
Social Security Number:
 Date of Birth:
 Phone:
Have you ever lived outside of Wisconsin within the past seven (7) years?   If 'yes', where?
Have you ever been convicted of, or do you presently have pending, charges for violations of law other than minor traffic violations:
In accordance with state law, convictions or pending charges will not be used or considered unless they are substantially related to circumstances. If the answer to the above question is "yes" please fill in the information below and attach a letter of explanation. If you have more than two convictions or pending charges, list them on a separate sheet.
ARREST OR CONVICTION INFORMATION
Charge
 Date of Pending charge / Conviction
 County and State
City
 State
 Amount of Fine
 Length of Jail Time
Remarks
 Length of Probation
Charge
 Date of Pending charge / Conviction
 County and State
City
 State
 Amount of Fine
 Length of Jail Time
Remarks
 Length of Probation
*Conviction means the final judgment of a verdict or a finding of guilty, a plea of guilty, or a plea of nolo contender, in any state or federal court of competent jurisdiction in a criminal case, regardless of whether an appeal is pending or could be taken. Conviction does not include a final judgment which has been expunged by pardon, reversed, set aside, or otherwise rendered invalid.
Volunteer Type:
I authorize the investigation of all statements contained herein and understand that any document relevant to this information may be reviewed by the agents of the Chippewa Falls Area Unified School District. I understand that my employment is not finalized until the background investigation has been completed.

I certify that the answers given by me in this application are true and correct without omissions of any kind. I agree that the District shall not be held liable in any respect if my employment is terminated because of false statements or answer omissions made by me in this application. In consideration of the school district’s review of this application, I hereby release the District as well as all providers of information from any liability and for any damage which may result from the furnishing and receiving of this information.

By Clicking the below Submit Button, I hereby certify that the statements above are true and correct to the best of my knowledge and belief.
No person shall be discriminated against or harassed in any action under any program of activity sponsored by the CFAUSD, solely by reason of age, race, creed, color, handicap/disability, marital or parental status, sex, national origin, ancestry, sexual orientation, arrest record, conviction record not materially related to the responsibilities of employment, membership in the national guard, state defense force or any reserve component of the military forces, or use or nonuse of lawful products outside the work place during nonworking hour.