E-Sign Act Disclosure
If you do not consent to proceed electronically contact One Source at 1-800-608-3645, and reference Client ID PLUS4842. You may now exit this page.
Please read all instructions before completing this form!
After submitting your request, you will be presented with an invoice that will allow you to pay via credit or debit card. Payment will need to be received before we can complete the background check. If you do not have a credit card or debit card please contact One Source for alternative payment arrangements.
The fee for the services provided by One Source is $32.00, payment for which is made directly to One Source and accompanies this request.
Please return your Health and Human Services Child and Adult Abuse Release to Betsy Kigin upon completing this form. Your Background Report will be incomplete until this form is returned.
The following information may be required by law enforcement agencies, local, state or federal governmental agencies or similar public bodies for positive identification purposes when checking public records. I understand that this information is confidential and will only be used for background screening purposes.
According to the Fair Credit Reporting Act you are to be provided with a copy of your rights according to the FCRA. Please click here for the
Summary of Consumer Rights According to the FCRA.
Email One Source with any special notes/comments regarding this applicant at:
Select Next to proceed to next screen.
Questions? Contact One Source at 402.933.9999 or 1.800.608.3645.
Process Credit Cards
Enter full legal first name.
Enter middle name or initial.
Enter full legal last name.
Enter suffix if applicable. EXAMPLE: Jr., Sr., III
Full Street Address
Please change if US is not the correct Country Code
Request Copy ?
Would you like a copy of the report ?
Enter social security number. Do not enter hyphens or dashes. EXAMPLE: 11122333
Birth Date (DOB)
Enter date of birth. Do not enter hyphens or dashes. EXAMPLE: 12101970
Drivers License Number
Enter Drivers License Number.
Enter Drivers License Issuing State.
Enter a phone number the applicant can be reached at between 8 am and 5 pm.
Enter an email address. REQUIRED for e signature on release
Intern Placement 3.3
County Criminal - Statewide If Available
Iowa Adult Abuse Registry
Iowa Child Abuse Registry