HTML Preview Apprenticeship Application Form page number 1.
Apprenticeship Application
For Volunteer Safety Instructors
Instructor Number #
assigned by Dept
State of Wisconsin
Department of Natural Resources (DNR)
PO Box 7921, Madison WI 53707-7921
dnr.wi.gov
Important
• This application is the first step for anyone wishing to participate in the instructor apprenticeship program.
• Applicants must be 18 years of age or older, be or become a graduate of the safety program they wish to teach and must not
have been convicted of a domestic violence violation or felony.
• Completion of this form is authorized by NR 19.30 Wisconsin Administrative Code and is required for consideration.
• Personally identifiable information on this form will be used during your character, background and criminal history checks, safety
course notifications, and may also be available for compliance with Open Records Requests per State Statutes 19.31-39.
• Completion and submittal of this application will initiate a complete character, background, and criminal history check in
accordance with State Statutes 23.33(5) (b), 29.591, 30.74, and 350.05(2) and information obtained will be reviewed by
Recreational Safety Wardens (RSW's) who are not at liberty to discuss their findings.
• After completion send application to your local Recreational Safety Warden (RSW) contact information on Page 2.
• If approved, a candidate has 18 months to complete their certification requirements.
• All volunteer instructors serve at the discretion of the Department.
• Candidates will be notified of application status.
• Candidates can obtain their own background check through a local law enforcement agency.
Safety Program(s) applying for:
ATV UTV Boating Hunter Ed Hunter Ed Internet Field Day
Bow Hunter Snowmobile Wingshooting
•
Are you a graduate of the safety course for which you are applying?
Yes No
Background
•
Have you ever been arrested, charged or convicted of an act related to domestic violence, children or other crimes?
Yes No
Background Check Release
I hereby empower the Department or its authorized representative bearing this release to obtain information and records pertaining to
me from any or all of the following sources: Selective Service System, any current or previous employer, any school, college, university
or other educational institution I may have attended and any law enforcement agencies (including criminal history record checks). I
understand that this information is necessary for determining my eligibility and suitability for certification as a Department of Natural
Resources Volunteer Safety Program Instructor. Therefore, I hereby release any individual or institution, including its officers,
employees, or related personnel, both individually and collectively, from any and all liability for damages of whatever kind, which may at
any time result to me, because of compliance with this authorization or request to release information or any attempt to comply with it.
Applicant's Signature
Date
Sponsor's Name Instructor # E-mail
Applicant Information
Applicant Name (PRINT full legal name)
First Last MI
Date of Birth
mm / dd / yyyy
Gender
Male
Female
DNR Customer Identification Number
CID #
Residence Address:
City State ZIP Code
County of residence
PO Box Address (if applicable)
City State ZIP Code E-mail
Phone Number(s)
Home: Cell: Work:
The following demographic information helps the Department determine our ability to provide access and services for all of our public.
Participation in this survey is voluntary.
Black (not of Hispanic origin) Asian or Pacific Islander American Indian or Alaskan Native
Hispanic
White (not of Hispanic origin) Multi-racial
National Origin
DNR USE ONLY
Local RSW Check
CCAP DNR Citations DOJ, CHRI & NCIC DOT
If candidate is approved, local warden check will be
completed after receiving the candidate's Instructor
Training Record and Application Form 8500-162
________________________________________________________________/ _________
RSW Signature. *If approved by RSW this application expires 18 months from this date
Yes - RSW approves candidate for apprenticeship
No - RSW does not approve
Page 1 of 2
Form 8500-161 (R 01/17)
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