Request For Adult Criminal History Form
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1
2MONROE COUNTY SHERIFF’S OFFICE
REQUEST FOR ADULT CRIMINAL HISTORY
Please type or print all information
1. Requesting agency or individual:
Name:___________________________________Phone__________________
Street address:____________________________________________________
City:________________________State__________Zip:___________________
2. Subject of the request:
Name:___________________________________________________________
Street address:____________________________________________________
City:________________________State__________Zip:___________________
Date of birth:_____________Sex:______Race:_____SSN:__________________
3. (Please check the appropriate line) The reason for the request is that this individual:
____
A.
Has applied for employment with a non‐criminal justice organization or individual;
____B.
Has applied for a license and has provided criminal data as required by law to be provided in
connection with the license;
____C.
Is a public official or a candidate for public office;
____D.
Is in the process of being apprehended by a law enforcement agency;
____E.
Is under arrest for the alleged commission of a crime;
____F.
Has charged his/her rights have been abused repeatedly by criminal justice agencies;
____G.
Is the subject of judicial decision or determination with respect to the setting of bond, plea
bargaining, sentencing or probation;
____H.
Has volunteered services involving contact with, care of, or supervision over a child placed,
matched or monitored by a social services or nonprofit agency;
____I.
Is residing in a location designated by the Department of Child Services or by juvenile court as an
out‐of‐home placement for a child at the time the child will reside in the location;
____J.
Has volunteered services at a public school (as defined in IC 20‐18‐2‐15) or non‐public school (as
defined in IC 20‐18‐2‐12) involving contact with, care of, or supervision over a student enrolled in
the school;
____K.
Is being investigated for welfare fraud by the state or county office of the Division of Family and
Children;
____L.
Is being sought by the parent locator service of the child support bureau of the Division of Family
and Children;
____M.
Is or was required to register as a sex and violent offender under IC 11‐8‐8; or
____N.
Has been convicted under any of the following:
•
Rape (IC 35‐42‐4‐1), if the victim is less than 18 years of age;
•
Criminal deviate conduct (IC 35‐42‐4‐2), if the victim is less than 18 years of age;
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