Charitable Organization Registration Statement Form - Wisconsin Department Of Safety And Professional Services Page 4
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4Wisconsin Department of Safety and Professional Services
EMPLOYER IDENTIFICATION NUMBER. Your employer identification number or your social security
number if you are a sole proprietorship must be submitted with your application on this form. If you do
not have a social security number you must submit a statement under oath or affirmation. If your social
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security number or a statement is not provided, your application will be denied.
A form for submitting a
statement that you do not have a social security number is available from the department.
(Please Print)
______________________________________________
Business Entity Name
FEIN
__________________________________________________________________________________________________
Type of Credential (License) applying for
The Department may not disclose the employer identification number or social security number collected above except to
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the Department of Workforce Development for purposes of administering the child and spousal support program,
to the
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Department of Revenue for the purpose of determining whether you are liable for delinquent taxes,
and to the federal
Healthcare Integrity and Protection Data Bank for the purpose of reporting adverse actions against health care
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practitioners.
DELINQUENT STATE TAXES; DELINQUENT SUPPORT
All applications for professional credentials are checked to determine whether the applicant is liable for delinquent state
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taxes. Under state law, the department must deny your application if you are liable for delinquent Wisconsin taxes.
If
you are liable for delinquent state taxes, pay the delinquent amount before the application process is completed. Retain
proof that you have satisfied the tax delinquency. If you have any questions about payment of delinquent taxes, please
contact your nearest Department of Revenue office or call (608) 261-6249. An application may be denied or a credential
suspended if an applicant or credential holder is delinquent in paying support or fails to comply with a subpoena or
warrant issued by the department of workforce development or a county child support agency related to support or
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paternity proceedings.
EMAIL ADDRESS:
Yes
No
Do you have an email address?
If yes, this field is required to receive your application status electronically.
EMAIL ADDRESS: Please print in ALL CAPS below or submit a printed copy if there is not enough space.
If no, your checklist will be sent by first class mail.
___________________
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Section 440.03 (11m), Wis. Stats.
Health Insurance Portability and Accountability Act (HIPAA)
of 1996
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Sections 49.22, and 440.13, Wis. Stats.
Section 440.14, Wis. Stats.
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Section 440.12, Wis. Stats.
Section 440.12, Wis. Stats.
This form is authorized by secs. 440.12 and 440.14, Wis. Stats. Making a false statement in connection with this
application may result in revocation or denial.
#296 (Rev. 8/13)
Ch. 440.41, Stats.
Page 4 of 4
Committed to Equal Opportunity in Employment and Licensing
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