Background Check Authorization

Background Check Authorization

Allied Health Industry
Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Maiden or Previous Last Name (if applicable):
Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Social Security Number (xxx-xx-xxxx)
Sex
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Class Location
WAIVER

I hereby give permission for Iowa Lakes Community College or it's agent to conduct an Iowa criminal history record check with the Division of Criminal Investigation and an Abuse Registry Check with the Iowa Department of Human Services.

Any information maintained by the DCI or Department of Human Services may be released as allowed by law.
Signature
Please verify that you are human
Should be Empty: