Common use of Other Required Information Clause in Contracts

Other Required Information. 1. Has any government or regulatory agency ever limited, denied, or revoked your license, certification, or registration to provide care, treatment, or educational services? If Yes, explain, including when and where it happened. Yes No 2. Has any government or regulatory agency ever denied you permission or restricted your ability to live on the premises of a care providing facility? If Yes, explain, including when and where it happened and the reason. Yes No 3. Have you been discharged from a branch of the US Armed Forces, including any reserve component? If Yes, indicate the year of discharge: Attach a copy of your DD214, if you were discharged within the last three (3) years. 4. Have you resided outside of Wisconsin in the last three (3) years? If Yes, list each state and the dates you resided there. Yes No Yes No 5. If you are employed by or applying for the State of Wisconsin, have you resided outside of Wisconsin in the last seven