Application for Iowa Criminal History

"*" indicates required fields

I hereby give permission to Thomas Rest Haven to conduct an Iowa criminal history and dependent adult abuse record check with the Iowa Division of Criminal Investigation and the Iowa Department of Human Services.

Last Name:*

Maiden Name:*

Other Last Names:*

First Name:*

Middle Name:*

Date of Birth:*

Social Security Number:*

Professional License Number:*

Have you resided or worked outside of the state of Iowa as a licensed or certified health care worker?*

Yes

No

If so, which states?*

Signature*

Date*

Phone

This field is for validation purposes and should be left unchanged.

Thomas Rest Haven does not and shall not discriminate on the basis of race, color, religion, creed, gender, gender expression, age, national origin, disability, mental status, age, veterans’ status, gender identity or gender expression, sexual orientation or military status, in any of its’ activities or operations.