Background Information Disclosure Addendum
Mercyhealth Campus
1000 Mineral Point Ave.
Janesville, WI 53548
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  • List all addresses from the past three years (include your current address)

  • Authorization:
    I hereby authorize Mercy Health, a Wisconsin based corporation, to investigate criminal records and I consent to a background check as stated by Wisconsin’s Act 27 and by the Healthcare Worker Background Check of 1996 (225 IL CS 16/25). You are not obligated to disclose sealed or expunged records of conviction or arrest, nor may Mercy Health inquire if you have had records sealed or expunged as state by the Criminal Identification Act, (225 IL CS 16/25). I understand that my employment is contingent upon satisfactory completion of a complete background check. I release from all liability persons, companies, or corporations and institutions supplying such information.
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