Application For Bail Enforcement Agency License/private Investigative Agency License/private Security Agency License (Page 3 of 3) in pdf

IOWA DEPARTMENT OF PUBLIC SAFETY

Authorization For Release of Personal Information

and Acknowledgement of Understanding

I, _________________________________________, do hereby authorize a review of and full disclosure of all records

concerning myself to any duly authorized agent of the Iowa Department of Public Safety whether the said records are of a

public, private or confidential nature.

The intent of this authorization is to give my consent for full and complete disclosure of records of educational institutions;

financial or credit institutions, including loans, the records of commercial or retail credit agencies (including credit reports

and/or ratings) and other financial statements of records whenever filed; medical and psychiatric treatment and/or

consultation, including hospitals, clinics, private practitioners and the U.S. Veteran’s Administration; employment and pre-

employment records, including background reports, efficiency ratings, complaints or grievances filed by me or against me and

the recollections of attorneys at law, or of other counsel, whether representing me or another person in any case, either

criminal or civil, in which I presently have, or have had an interest.

I also certify that any person(s) who may furnish such information concerning me shall not be held accountable for giving this

information; and I do hereby release said person(s) from any and all liability which may be incurred as a result of furnishing

such information. I further release the Iowa Department of Public Safety from any and all liability which may be incurred as a

result of collecting such information.

A photocopy of this release form will be valid as an original thereof, even though the said photocopy does not contain an

original writing of my signature.

I have read and fully understand the contents of the application materials including the Iowa Code Chapter 80A and 661 Iowa

Administrative Code Chapter 2 which regulate the licensing of private investigative, private security and bail enforcement

agencies.

I have read and fully understand the contents of this “Authorization for Release of Personal Information and

Acknowledgement of Understanding”.

___________________________________________

Signature of Applicant

DO NOT EMAIL – SEND APPLICATION FORMS AND FEES TO:

Bail Enforcement/Private Investigative/Security Licensing

Program Services Bureau

Administrative Services Division

Iowa Department of Public Safety

215 East 7

Street, 4

Floor

Des Moines, Iowa 50319-0045

Application For Bail Enforcement Agency License/private Investigative Agency License/private Security Agency License Page 3