Applicant - Complete personal information in Top Box and sign at bottom of form.
IOWA HEALTH CARE FACILITY (135C) RECORD CHECK
Form C
7344-C
ACCOUNT NUMBER___________________
Friendship Home
TO:
Iowa Division of Criminal Investigation
FROM:
st
Bureau of Identification, 1
Floor
714 N Division St
th
215 E 7
Street
Des Moines, IA 50319
Audubon, IA 50025
(515) 281-5138 (Voice-days)
Phone #
712-563-2651
(515) 281-4776 (Voice-nights)
712-563-2342
(515) 242-6876 (Fax)
Fax #
I am requesting an IOWA CRIMINAL HISTORY check on:
(Type or Print Legibly)
REQUEST
________________________
________________________
________________________
Last Name
First Name
Middle Name
(mandatory)
(mandatory)
(recommended)
Maiden Name
_____/_____/_____
_______
________-________-________
Date of Birth
Sex
Social Security Number
(mandatory)
(mandatory)
(recommended)
Signature of Requester
(Friendship Home signature only
Applicant to sign at bottom of form)
(DCI Use Only)
RESULTS
As of ____________________, a Name and date of birth check revealed:
No CCH record found
No record of founded Dependent
Adult Abuse
CCH record attached
Potential DAAR “hit” send 2310 to
DHS
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.
______________________________________________
_________________________
(Applicant)
Signature
Date
Digital Signature - Follow directions on screen to complete
Form No. 595-1489 (4/07)