Form 595-1489 - Non-Law Enforcement Record Check Request Form A - Iowa Division Of Criminal Investigation
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1
2STATE OF IOWA
NON-LAW ENFORCEMENT RECORD CHECK REQUEST
FORM A
ACCOUNT NUMBER___________________
TO:
Iowa Division of Criminal Investigation
FROM:
st
Bureau of Identification, 1
Floor
th
215 E 7
Street
Des Moines, IA 50319
(515) 725-6066
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)
(mandatory)
(recommended)
_____/_____/_____
_______
________-________-________
Date of Birth
Sex
Social Security Number
(mandatory)
(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
Form No. 595-1489 (4/07)
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