State Of Iowa Non-Law Enforcement Record Check Request Form A printable pdf download

State Of Iowa Non-Law Enforcement Record Check Request Form A

State of Iowa

NON-LAW ENFORCEMENT RECORD CHECK REQUEST

FORM A

ACCOUNT NUMBER DHS

Iowa Division of Criminal

FROM:

TO:

Investigation

Bureau of Identification, 1st Floor

215 E 7th Street

Des Moines, Iowa 50319

(515) 281-4776

Phone #

(515) 725-6080 (fax)

Fax #

I am requesting an IOWA CRIMINAL HISTORY check on:

(Type or Print Legibly)

REQUEST

Last Name

First Name

Middle Name

(mandatory)

(recommended)

Date of Birth

Sex

Social Security Number

(mandatory)

(recommended)

Signature of Requester

There is a separate Form “A” required for each last name submitted

(DCI Use Only)

RESULTS

As of ______________________________________, a name and date of birth check revealed:

CCH record attached

No CCH record found

DCI initials _______________

WAIVER

I hereby give permission for the above requesting official to conduct an Iowa criminal history

record check with the Division of Criminal Investigation. Any information maintained by the

DCI may be released as allowed by law.

Signature

Date

595-1489 (Rev. 4/07)

State Of Iowa Non-Law Enforcement Record Check Request Form A