DIVISION OF PROFESSIONAL CREDENTIAL PROCESSING
INSTRUCTIONS FOR APPLICATION FOR PREDETERMINATION (#3085)
IMPORTANT NOTE: By submitting this form you are requesting a pre-application review of your conviction record. It is an
optional, preliminary step that occurs prior to submitting an initial credential application and meeting credentialing requirements.
(Please see below and Question 1 on Page ii for more information.)
PROFESSION
PREDETERMINATION FORM NUMBER
Aesthetician, Aesthetician Instructor or Aesthetics Establishment; Barbering,
Barbering Instructor, Barbering Apprentice, or Barbering Establishment;
Cosmetologist, Cosmetologist Instructor, Cosmetology Apprentice or
Cosmetology Establishment; Electrologist, Electrologist Instructor or
Electrology Establishment; or Manicurist, Manicurist Instructor or Manicuring
Establishment
DO NOT USE THIS FORM (#3085)
USE FORM #3253
Advanced Practice Nurse Prescriber, Licensed Practical Nurse, Nurse
Midwife, Registered Nurse, Wholesale Distributor of Prescription Drugs,
Third Party Logistics Providers, Licensed Midwives, Private Security Person,
Private Detective, Firearms Certifier, and Private Detective/Security Agency
DO NOT USE THIS FORM (#3085)
USE FORM #3086
All other health and business professions and all trades professions
USE THIS FORM #3085
The Fair Employment Act (Wis. Stat. §§ 111.31-111.395) prohibits employment and licensing discrimination on the basis of a
conviction record unless the circumstances of the offense substantially relate to the circumstances of the particular job or licensed
activity. An individual who does not possess a credential with the Department may use this form to apply, pursuant to Wis. Stat. §
111.335(4)(f), for a determination of whether his or her conviction record would disqualify him or her from being credentialed. The
offenses or kinds of offenses that may result in a refusal, bar, or termination of licensure available on the DSPS website, Offenses
that May Result in Refusal, Bar, or Termination of Licensure.
Submission of a predetermination application is optional and allows an individual to learn if his or her conviction record would
disqualify him or her for a particular credential before applying for that credential. Only submit this predetermination
application if you have been convicted of a felony, misdemeanor, or other violations of federal or state law in this state or
any other state AND seek a determination whether your conviction record would disqualify you from obtaining a particular
credential before submitting a credential application and meeting all credentialing requirements. (You do not need to report
municipal ordinance violations or dismissed charges.)
If you submit this predetermination application and receive a favorable predetermination decision (i.e., that your conviction record
would not disqualify you from obtaining a particular credential):
• You will not be required to submit additional information related to those convictions (such as personal statements or
court documents) with Convictions and Pending Charges Form (2252) (or Form 2255 for Trades) when you submit your
credential application.
• If you receive any new convictions or pending charges after the date of your favorable predetermination decision,
you will need to submit all required documentation for each new conviction or pending charge along with Form 2252 (or
Form 2255 for Trades) and your credential application.
• You will only need to pay the difference between the predetermination application fee and the initial credential fee when
you apply for a credential if you apply within 1 (one) year of the predetermination decision. For example, if the $68
predetermination fee is paid and the initial credential fee is $75, you will owe another $7 for the initial credential fee. This
does not include any fees for exams or subsequent background check fees. (If the credential fee is less than $68, no
refunds will be issued.)
• You will still need to meet all credentialing requirements (i.e., training/education, exams, etc.). A favorable
predetermination decision does not guarantee licensure.
#3085 (Rev. 4/5/2024)
Wis. Stat. ch. 111
i
Committed to Equal Opportunity in Employment and Licensing
FINGERPRINTING: Some professions require fingerprinting. If you are seeking a predetermination of your conviction record to
obtain a credential listed on Form 2687 you will receive instructions on how to obtain fingerprints after the Department receives
your predetermination application and a signed Form 2687, Authorization for Release of FBI Information. (Fingerprinting is not
required for Trades Professions.)
Wisconsin Department of Safety and Professional Services
Office Location: 4822 Madison Yards Way
LicensE Portal: https://license.wi.gov
Madison, WI 53705
Phone Number: (608) 266-2112
Email: dsps@wisconsin.gov
Website: http://dsps.wi.gov
Wisconsin Department of Safety and Professional Services
FREQUENTLY ASKED QUESTIONS
1. What should I consider before submitting an Application for Predetermination?
• An Application for Predetermination (3085) is an optional, preliminary step that occurs prior to submitting an initial
credential application and meeting credentialing requirements. If the predetermination conviction record review
results in a decision letter that states your conviction record would not disqualify you from receiving a specific
credential, you then need to submit the credential application, Convictions and Pending Charges Form
(#2252) (or Form 2255 for Trades), and meet all credentialing requirements. (See last paragraph on Page i.)
• Seeking a predetermination (Form 3085) is an optional step. Alternatively, you may forgo the predetermination
process and simply submit your initial credential application along with the Convictions and Pending Charges
Form (#2252) (or Form 2255 for Trades) and all credentialing requirements. Convictions and pending charges will
be reviewed as part of the application process.
2. What convictions do I need to report?
• List all felonies, misdemeanors, and other violations of federal or state law in Wisconsin or any other state for
which you have ever been convicted. This includes convictions resulting from a plea of no contest, a guilty plea, or
verdict.
• You do not need to report municipal ordinance violations or dismissed charges.
3. If my conviction was expunged, do I need to report or submit anything?
• Technically, there was a conviction at one point in time; therefore, you need to disclose the conviction and provide
all documents required. Also, include a court document stating the conviction was expunged.
4. What do I do if records are no longer available due to the length of time that has passed since the conviction?
• Include a personal statement describing each offense along with an explanation of the penalties imposed and
verification that you completed all requirements. State that the records are no longer available in your personal
statement and include a letter from the appropriate agency/police department, and/or court records custodian
confirming the unavailability of the records.
5. Do I need to report or submit anything about minor traffic violations, e.g., a speeding ticket?
• There is no need to disclose minor traffic violations such as speeding, seat-belt violations, and parking tickets that
resulted in a forfeiture. However, you must disclose any traffic offense that resulted in a misdemeanor or felony
conviction.
6. How long does it take to review these documents?
• The time period for conviction review varies depending on whether all information is complete, all documentation
is received, and/or whether it needs to be reviewed by a licensing Board attached to the Department, etc.
7. What are certified court records and where do I get them?
• These are records certified as true and correct by the Office of the Clerk of Courts and may include judgment of
conviction, police report/incident report/criminal complaint, court-ordered assessment report, etc.
• Records may be obtained from the Office of the Clerk of Courts in the county in which your case was heard or the
relevant police department.
8. If I was underage at the time of the offense, do I need to report or submit anything?
• If you were convicted in adult court, report the conviction. Disclose any felony, misdemeanor, and other violations
of federal or state law in Wisconsin or any other state received in adult court and submit all court documents and
verification that you have complied with all requirements.
#3085 (Rev. 4/5/2024)
Wis. Stat. ch. 111
ii
Committed to Equal Opportunity in Employment and Licensing
IMPORTANT NOTE: DO NOT SUBMIT THIS FORM UNLESS ALL DOCUMENTATION REQUESTED IS INCLUDED.
If you need assistance with submitting your predetermination application, select "Request Support" from the blue toolbar in
LicensE, https://license.wi.gov.
DIVISION OF PROFESSIONAL CREDENTIAL PROCESSING
APPLICATION FOR PREDETERMINATION (#3085)
The Fair Employment Act (Wis. Stat. §§ 111.31-111.395) prohibits employment and licensing discrimination on the basis of a
conviction record unless the circumstances of the offense substantially relate to the circumstances of the particular job or licensed
activity.
An individual who does not possess a credential with the Department may use this form to apply, pursuant to Wis. Stat. §
111.335(4)(f)
, for a determination of whether his or her conviction record would disqualify him or her from being credentialed.
By submitting this form, you are requesting a pre-application review of your conviction record. It is an optional, preliminary step
that occurs prior to submitting an initial credential application and meeting credentialing requirements. (Please see Page i and
Question 1 on Page ii for more information.)
PROFESSION YOU WISH TO ENTER:
PLEASE TYPE OR PRINT IN INK
Your name, address, phone number, and e-mai
l
address
a
re available
to
t
he public
.
Check box to withhold street
address/PO Box, phone number, and email address from lists of 10 or more individuals (Wis. Stat. § 440.14).
Last Name
First Name
MI
Former / Maiden Name(s)
List All Other Names Used
Address (street) (city) (state) (zip code) Daytime Phone Number
- -
Mailing Address (if different) (street) (city) (state) (zip code) Date of Birth
/ /
Social Security Number Your Social Security Number must be submitted with your application on this form. If you
do not have a Social Security Number, you must complete Form 1051. The Department may
not disclose the Social Security Number collected except as authorized by law.
- -
Email Address
#3085 (Rev. 4/5/2024)
Wis. Stat. ch. 111
Page 1 of 4
Committed to Equal Opportunity in Employment and Licensing
IMPORTANT NOTE: DO NOT SUBMIT THIS FORM UNLESS ALL DOCUMENTATION REQUESTED IS INCLUDED.
If you need assistance with submitting your predetermination application, select "Request Support" from the blue toolbar in
LicensE, https://license.wi.gov.
Wisconsin Department of Safety and Professional Services
Office Location: 4822 Madison Yards Way
LicensE Portal: https://license.wi.gov
Madison, WI 53705
Phone Number: (608) 266-2112
Email: dsps@wisconsin.gov
Website: http://dsps.wi.gov
Wisconsin Department of Safety and Professional Services
List all CONVICTIONS for felony, misdemeanor, and other violations of federal, or state law in Wisconsin or any other
state. You do not need to report municipal ordinance violations or dismissed charges. Attach additional sheet(s) if necessary.
*Please indicate Felony=F or Misdemeanor=M.
Conviction
Conviction Date
Location (City, County, State)
*F or M
/ /
/ /
/ /
/ /
/ /
/ /
APPLICATION IS NOT COMPLETE UNTIL ALL OF THE FOLLOWING DOCUMENTS HAVE BEEN RECEIVED.
FOR EACH CONVICTION OR VIOLATION LISTED ABOVE, YOU MUST SUBMIT THE FOLLOWING:
Certified copies of the Police Report or Criminal Complaint
Certified copies of the Judgment of Conviction
Personal Statement (Only needed if certified copies of Police Report or Criminal Complaint and Judgment of Conviction do
not exist and/or your responses to Questions 1 through 9 require additional explanation.)
NOTE: Do not submit Consolidated Court Automation Program (CCAP) or other online court access printouts. They do
not satisfy documentation requirements. During the Department’s review of the predetermination application, you may be
asked to submit additional information.
YOU MUST ANSWER THE FOLLOWING QUESTIONS. (Attach additional sheets if necessary.)
1.
Have you ever been sentenced by a court to participate in an alcohol or other drug assessment? If YES,
provide a copy of the assessment and include a statement describing your current use of alcohol
and/or drugs.
Yes No
2.
A. Have you ever been sentenced by a court to participate in an alcohol or other drug treatment or
counseling program? If YES, complete Question 2B.
Yes No
B. If
YES to Question 2A, did you successfully complete the program? If YES, attach the
certificate of completion/discharge summary.
NOTE: If you did not complete the program, attach a statement explaining why.
Yes No
3.
A. Have you ever been placed on probation and/or extended supervision? If YES, complete
Question 3B.
Yes No
B. If YES t
o Question 3A, did you successfully complete probation and/or extended supervision?
If YES, provide evidence such as a release document or a Department of Corrections (DOC)
document.
NOTE: If you are currently on probation or extended supervision, provide a letter from your
probation officer or other official describing your probation or extended supervision requirements
and your compliance with those requirements.
Yes No
4.
A. Have you ever been placed on parole?
If YES, complete Question 4B.
Yes No
B. If YES t
o Question 4A, did you successfully complete parole? If so, provide evidence such as a
release document or Department of Corrections (DOC) document.
NOTE: If you are currently on parole, provide a letter from your parole officer describing your
parole requirements and your compliance with those requirements.
Yes No
5.
Have you ever served in the U.S. military or National Guard?
If YES, please include a copy of any
Department of Defense (DOD) Form 214s or National Guard Bureau (NGB) 22s you wish to have
considered as evidence of rehabilitation.
Yes No
#3085 (Rev. 4/5/2024)
Wis. Stat. ch. 111
Page 2 of 4
Committed to Equal Opportunity in Employment and Licensing
Wisconsin Department of Safety and Professional Services
6.
Do you have any mitigating (lessening the gravity of an offense or mistake) circumstances or social
conditions surrounding the commission of the offense(s)? If YES, please include details in an attached
personal statement.
Yes No
7.
Since your offense(s), do you have any evidence of rehabilitation, such as employment, education,
participation in treatment, payment of restitution, or any other activity that you wish to have considered as
evidence of rehabilitation? If YES, please include evidence of such and/or a personal statement.
Yes No
8.
A. Did you serve a jail or prison sentence? If YES, provide evidence such as a release document or
Department of Corrections (DOC) document and complete Question 8B.
Yes No
B. If YES t
o Question 8A, do you have any letters of reference by persons (such as employers, clergy,
counselors, etc.) who have been in contact with you since your release from jail or prison that you
wish to have considered as evidence of rehabilitation? If YES, please provide them.
Yes No
9.
Are you registered or licensed in any other profession(s)? If YES, state what profession(s) and in what
state(s), including license number(s). (Attach additional sheets if necessary.)
Yes No
PERSONAL STATEMENT FOR EACH CONVICTION (Only needed if certified copies of Police Report or Criminal
Complaint and Judgment of Conviction do not exist and/or your responses to questions 1-9 require additional explanation.)
(Attach additional sheets if necessary.)
A personal statement should describe the events that led to each offense and conviction listed on Form #3085, along with an
explanation of the penalties imposed, and verification that you completed all sentencing requirements. The statement should
address the “who,” “what,” “when,” “where,” “how,” and “why” of the circumstances that led to each conviction.
Example of an Adequate Personal Statement: In 2016, I was convicted of “Theft-Movable Property <=$2500” in Milwaukee
County. When I was 19, I found a wallet on the ground outside of a department store and made the poor decision to use a credit
card I found in the wallet. I purchased multiple clothing items from the store with this card. I was arrested, convicted of a
misdemeanor, ordered to pay a fine and restitution, and placed on probation for six months. Attached to this statement are copies of
the Criminal Complaint and the Judgment of Conviction, records showing that I successfully paid the fine, restitution, and a letter
from my probation agent verifying successful completion of probation.
CONVICTION(S):
#3085 (Rev. 4/5/2024)
Wis. Stat. ch. 111
Page 3 of 4
Committed to Equal Opportunity in Employment and Licensing
Wisconsin Department of Safety and Professional Services
CONTINUING DUTY OF DISCLOSURE
I understand that I have a continuing duty of disclosure during the application process. If information I have provided in this
application becomes invalid, incorrect, or outdated, I understand that I am obliged to provide any necessary information to ensure the
information on my application remains current, valid, and truthful. I understand that credentialing authorities may view acts of
omission as dishonesty and that my duty of disclosure during the application process exists until a predetermination decision is made.
AFFIDAVIT OF APPLICANT
I state that I am the person referred to in this document and that all the information, which I provided above, is true in every respect. I
understand that false or forged statements made in this document or in connection with an application for a credential, or failing to
provide relevant information, may be grounds for denial of an application, revocation of a credential granted to me, or criminal
prosecution. I confirm that I have included all information and documentation requested by this form. I understand that my
application is incomplete until the Department receives all requested information and documentation. Incomplete applications
will not be processed or reviewed until the Department receives all requested information and documentation.
Signature
:
Date: / /
(If unable to provide a digital signature print and sign form.)
#3085 (Rev. 4/5/2024)
Wis. Stat. ch. 111
Page 4 of 4
Committed to Equal Opportunity in Employment and Licensing
