Dear Education Applicant:
Thank you for your interest in applying to the Indian Hills Community College Education program. Our
program prepares the student to become a classroom teacher in a public or private school district
anywhere from Preschool to 12
grade. By entering the Education program, the student is on a path to
gain teacher licensure in the state of Iowa or any other state. According to the Iowa Board of
Educational Examiners (BOEE), a state background check and a national fingerprint background check
and a check of the sex offender and child and dependent adult abuse registries is to be conducted on all
applicants preparing to obtain an Iowa teaching licensure (2019). Therefore, this program is closed to all
applicants with a felony record, conviction of a serious misdemeanor crime or any crime of immorality.
Background checks are required pending entrance to the Education program since it would be unfair to
the student for Indian Hills Community College to allow a student to complete the entire education
curriculum only to be refused acceptance into a 4-year institution, licensure and or employment.
There are two documents to complete. One is a Questionnaire for Participation Form and the other is
the Criminal History Record Check Authorization for Release Form. The Questionnaire for Participation
Form is required to be in compliance with Iowa law which is states that 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, the applicant states that you have not been charged with or convicted of the above listed
offenses anywhere in the United States. Again, it would be unfair for an applicant to successfully
complete the education program only to be turned away from a 4-year institution or unemployable in
the field.
Along with the two forms, a check, money order or cashiers check payable to Indian Hills Community
College in the amount of $20.00 is required as a processing fee and should be placed in the same
envelope with the two forms.
Upon receipt of the completed forms and money, we will submit the Criminal History Record Check
Authorization for Release Form to the Iowa Department of Criminal Investigations (DCI) to perform the
background check. A reply is usually received with a day or two. At that point you will be allowed into
the program. It is very important to complete the forms and send the processing fee as soon as possible
to be accepted into the Education program prior to the start of Fall term. Your documentation will not
be processed without both forms or the money to process the forms.
Again, please complete both forms and add a check, money order or cashier’s check and mail to:
ATTN: Program Director, Education
Indian Hills Community College
525 Grandview Ave
Ottumwa, IA 52501
We appreciate your interest in the Indian Hills Community College Education program and sincerely look
forward to working with you. If you have any questions feel free to contact me at (641) 683-5111, ext.
1835 or by email at
Deb Vos Ed. S
Program Director, Education
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.
Yes NO
1. Have you ever been charged or convicted of any felony offense
(Including those under the Uniform Code of Military Justice) ___ ___
2. Have you ever been charged with or convicted of a firearms or
explosives offense? ___ ___
3. Have you ever been charged with, convicted of or is there currently
any charges pending against you for domestic abuse? ___ ___
4. Have you ever been charged with or convicted of any offense(s)
related to alcohol or drugs? ___ ___
5. In the last 5 years, have you been arrested for, charged with, or
convicted of any offense(s) not listed to questions 1-4 above?
(leave out traffic fines of less than $150 unless the violation was
alcohol or drug related.) ___ ___
Print Your Full Name
_________________________ ___________
Signature Date
__________________________________________ _______________
Address City 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 removal from the class and the Education
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Criminal History Record Check
Request Form
DCI Account Number:
(if applicable)
Iowa Division of Criminal Investigation
Support Operations Bureau, 1
215 E. 7
Des Moines, Iowa 50319
(515) 725-6066
(515) 725-6080 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)
Waiver Information: Without a signed waiver from the subject of the request, a complete criminal history record may not
releasable, per Code of Iowa, Chapter 692.2. For complete criminal history record information, as allowed by law, always
a waiver signature from the subject of the request.
Release: I hereby give permission for the above requesting official to conduct an Iowa criminal history record check with the Division of Criminal
(DCI). Any criminal history data concerning me that is maintained by the DCI may be released as allowed by law.
Waiver Signature:
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