Yes No

 Yes No

 Yes No


High School

 Yes No


 Yes No

Trade, Business,Corresp. School

 Yes No

Employment History (List most recent first)

From To Employers Name and phone number Position and Salary Reason for leaving


Name and Phone Number Business Name Years Acquainted

Have you ever been convicted of a felony? If yes please explain.

I authorize all persons and companies named above and other determined appropriate, except my present employer is so noted, to furnish any information regarding me whether or not it is on their records, and hereby release them from all liability for damage for providing the information. In addition, I understand that a routine inquiry may be made to validate the information I have placed on this application. Upon my written request, additional information as to the nature and scope of the inquiry, if one is made, will be provided to me. I further understand that any
employment offered to me will not be for any definite period of time and is subject to termination, with or without cause, by the employer or at my own election at any time for any reason. I understand that my employment is at will and that this policy cannot be changed except in a written document signed by an authorized officer of the company and also signed by me.

Iowa Department of Human Services

Request for Dependent Adult Abuse Registry Information

To request information about dependent adult abuse, complete this form and mail it to: Central Abuse Registry, Iowa Department of Human Services, 401 SW 7th Street, Suite G, Des Moines, IA 50309-3574.
Note: Information will be released only to people who have access to it under Iowa Code section 235B.6.
Criminal Penalties (235B.12)
1. Any person who willfully requests, or seeks to obtain dependent adult abuse information under false pretenses, or who willfully communicates or seeks to communicate dependent adult abuse information to any agency or person except in accordance with section 235B.6 and 235B.8, or any person connected with any research authorized pursuant to section 235B.6 who willfully falsifies dependent adult abuse information or any records relating thereto, is guilty of a serious misdemeanor. Any person who knowingly, but without criminal purposes, communicates or seeks to communicate dependent adult abuse information except in accordance with section 235B.6 and 235B.8 shall be guilty of a simple misdemeanor.
2. Any responsible grounds for belief that a person has violated any provision of this chapter shall be grounds for the immediate withdrawal of any authorized access such person might otherwise have to dependent adult abuse information.
Redissemination of Dependent Adult Abuse Information (235B.8)
A recipient of dependent adult abuse information shall not redisseminate (release) the information, except when all of the following conditions apply:
1. The redissemination is for official purposes in connection with prescribed duties or, in the case of a health practitioner, pursuant to professional responsibilities.
2. The person to whom the information would be redisseminated would have independent access to the same information under section 235B.6.
3. A written record is made of the redissemination, including the name of the recipient and the date and purpose of the redissemination.
4. The written record is forwarded to the Central Abuse Registry within 30 days of the redissemination.

STATE OF IOWA Criminal History Record Check Request Form

I am requesting an Iowa Criminal History Record Check on:

 Male Female

Waiver Information: Without a signed waiver from the subject of the request, a complete criminal history record may not be releasable, per Code of Iowa, Chapter 692.2. For complete criminal history record information, as allowed by law, always obtain a waiver signature from the subject of the request.

Waiver Release: I hereby give permission for the above requesting official to conduct an Iowa criminal history record check with the Division of Criminal Investigation (DCI). Any criminal history data concerning me that is maintained by the DCI may be released as allowed by law.

Waiver Information:

Iowa law does not require a waiver. However, without a signed waiver from the subject of the request any arrest over 18 months old, without a final disposition, cannot be released to a non-law enforcement agency.

Deferred judgments where DCI has received notice of successful completion of probation also cannot be released to non-law enforcement agencies without a signed waiver from the subject of the request.

If the "No Iowa Criminal History Record found with DCI" box is checked, it could mean that the information on file is not releasable per Iowa law without a waiver.

General Information:

The information requested is based on name and exact date of birth only. Without fingerprints, a positive identification cannot be assured. If a person disputes the accuracy of information maintained by the Department, they may challenge the information by writing to the address on the front of this form or personally appearing at DCI headquarters during normal business hours.

The records maintained by the Iowa Department of Public Safety are based upon reports from other criminal justice agencies and therefore, the Department cannot guarantee the completeness of the information provided.

The criminal history record check is of the Iowa Central Repository (DCI) only. The DCI files do not include other states’ records, FBI records, or subjects convicted in federal court within Iowa.

In Iowa, a deferred judgment is not considered a conviction once the defendant has been discharged after successfully completing probation. However, it should be noted that a deferred judgment may still be considered as an offense when considering charges for certain specified multiple offense crimes, i.e. second offense OWI. If a disposition reflects that a deferred judgment was given, you may want to inquire of the individual his or her current status.

A deferred sentence is a conviction. The judge simply withholds implementing a sentence for a certain probationary period. If probation is successful, the sentence is not carried out.

Any questions in reference to Iowa criminal history records can be answered by writing to the address on the front of this form or calling (515) 725-6066 between 8:00 a.m. and 4:30 p.m., Monday - Friday.

REMINDER - (1) Send in a separate Request Form for each last name, (2) a fee is required for each last name submitted, (3) a completed billing form must be submitted with all request(s).

Iowa law requires employers to pay the fee for potential employees' record checks.