E-Sign Act Disclosure
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Coe College

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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.

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First NameEnter full legal first name.
Middle NameEnter middle name or initial.
Last NameEnter full legal last name.
SuffixEnter suffix if applicable. EXAMPLE: Jr., Sr., III
Street AddressFull Street Address
Zip Code
Country Code Please change if US is not the correct Country Code
Request Copy ?Would you like a copy of the report ?
SSNEnter 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 NumberEnter Drivers License Number.
Issuing StateEnter Drivers License Issuing State.
Phone NumberEnter a phone number the applicant can be reached at between 8 am and 5 pm.
Email AddressEnter an email address. REQUIRED for e signature on release
  Intern Placement 3.3
  County Criminal
  County Criminal - Statewide If Available  Iowa Adult Abuse Registry
  Iowa Child Abuse Registry