Dear Criminal Justice Applicant:
Thank you for your interest in applying for the Indian Hills Criminal Justice program. We feel that our
program is one of the best in the nation with the highest standards for ethics, integrity and
professionalism. All applicants to this program must complete a questionnaire for participation in the
program and undergo a criminal background check. This program is closed to all applicants with a felony
record, conviction of a serious misdemeanor crime or any crime of moral turpitude.
Background checks are required for the following reasons. It would be unfair for Indian Hills to allow a
student to complete the entire criminal justice program only to be refused employment because of a
felony or serious misdemeanor conviction. This program also demands completion of two firearms
qualification courses. Federal law prohibits individuals convicted of domestic abuse from possessing a
firearm.
The questionnaire for participation form is required as well for the following reasons. In accordance with
Iowa law this institution can only receive a criminal background check for violations and convictions in the
State of Iowa. In completing and signing this form you, as an applicant into this program, are stating that
you have not been charged with or convicted of the listed offenses anywhere in the United States. Again,
it would be unfair for an applicant to successfully complete the criminal justice program only to be
unemployable in the field.
Included with this letter you will receive both the authorization for release form and the questionnaire for
participation form. Please complete them both and return them to:
ATTN Criminal Justice
Indian Hills Community College
525 Grandview Ave
Ottumwa, IA 52501
Also, a check or money order payable to Indian Hills in the amount of $20.00 is required for the
processing fee and should be placed in the same envelope. Upon receipt of the completed forms and
check, we will submit the form to the Iowa Department of Criminal Investigations (DCI) to perform the
background check. A reply is usually received with a day or two. It is very important to complete the
forms and send the processing fee as soon as possible to be accepted into the criminal justice
program prior to the start of fall term.
We appreciate your interest in the Indian Hills Criminal Justice program and sincerely look forward to
seeing you. If you have any questions feel free to contact me at (641) 683-5111, ext. 1839 or by email at
Tim.King@indianhills.edu.
Sincerely,
Tim King
Program Director, Criminal Justice Department
QUESTIONNAIRE FOR PARTICIPATION
IN THE INDIAN HILLS COMMUNITY COLLEGE
CRIMINAL JUSTICE PROGRAM
YOUR POLICE RECORD
For this item, report information regardless of whether the record in your case has been “sealed” or otherwise
stricken from the court record. The single exception to this requirement is for certain convictions under the Federal
Controlled Substances Act for which the court issued an expungement order under the authority of 21 U.S.C. 844 or
18 U.S.C. 3607.
1.
Have you ever been charged or convicted of any felony offense
(Including t
hose under the Uniform Code of Military Justice)
YES
NO
2.
Have you ever been charged with or convicted of a firearms or
explosives o
ffense?
3.
Have you ever been charged with, convicted of or are there currently
any ch
arges pending against you for domestic abuse?
4.
Have you ever been charged with or convicted of any offense(s)
related to al
cohol or drugs?
5.
Have you been arrested for, charged with, or
convicted of any offense(s) not listed to questions 1-4 above?
(leave o
ut traffic fines of less than $150 unless the violation was
alcohol or d
rug related.)
Print Your Full Name
Signature
Date
Address
Phone#
Declaration – I declare that the information that I have given is correct, and I understand that
any attempt to give false information could lead to denial of entrance into or removal from the
Criminal Justice Program.
click to sign
signature
click to edit
STATE OF IOWA
Criminal History Record Check
Request Form
DCI Account Number:
(if applicable)
To:
Iowa Division of Criminal Investigation
From:
Support Operations Bureau, 1
st
Floor
215 E. 7
th
Street
Des Moines, Iowa 50319
(515) 725-6066
(515) 725-6080 Fax
Phone:
Fax:
I am requesting an Iowa Criminal History Record Check on:
Iowa Criminal History Record Check Results
(DCI use only)
As of , a search of the provided name and date of birth revealed:
No Iowa Criminal History Record found with DCI
Iowa Criminal History Record attached, DCI #
DCI initials
First Name (mandatory)
Middle Name (recommended)
Date of Birth (mandatory)
Gender (mandatory)
Social Security Number (recommended)
Male
Female
Waiver Information: Without a signed waiver from the subject of the request, a complete criminal history record may not
be
releasable, per Code of Iowa, Chapter 692.2. For complete criminal history record information, as allowed by law, always
obtain
a waiver signature from the subject of the request.
Waiver
Release: I hereby give permission for the above requesting official to conduct an Iowa criminal history record check with the Division of Criminal
Investigation
(DCI). Any criminal history data concerning me that is maintained by the DCI may be released as allowed by law.
Waiver Signature:
click to sign
signature
click to edit
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