RELEASE/WAIVER Authorizing a Criminal Background Check For Court Interpreters (All information is required. This form must be signed before a Notary Public) INTERPRETER NAME (Print): ______________________________________________________________ Last Name First Name Middle Name MAIDEN NAME: __________________________________________________________________________ OTHER NAMES: __________________________________________________________________________ Birth date: _________________________ Social Security #: __________ - ______- __________ Race: _____________________________ Gender: ____ Female ____ Male PRESENT ADDRESS: Street: _________________________________________________________________ City, State, Zip Code: ____________________________________________________________________ Pursuant to Iowa Rule of Court 14.1(1), I hereby authorize the office of the State Court Administrator for the Iowa Judicial Branch to make inquiry of any and all criminal justice agencies, military authorities and /or other agencies or individuals for purposes of determining the nature, dates and extent, including dispositions, of any criminal history information said agencies or individuals might possess pertaining to myself. I understand that the information obtained pursuant to a search of criminal records may be deemed sufficient by Iowa’s State Court Administrator or a Chief Judge of a judicial district to deny my appointment as a court interpreter. I further understand that any information obtained will be used only for purposes of determining my eligibility for court interpreting unless such information indicates evidence of an unresolved criminal matter. In such event, the proper authorities would be notified. Date: _____________________ __________________________________________________ Interpreter’s Signature (before a Notary Public) State of Iowa ) ) County of ____________________________________ ) ss: This document was signed and acknowledged before me on this day, ____________________, 20______. (month / day) (year) ________________________________________ (Notary’s Seal or Stamp) ________________________________________________ Signature: Notary Public in and for the State of Iowa Interpreters: Mail the original copy of this page (with original signatures) to the State Court Administrator’s Office (see address below) Sheriff’s Office: Please return criminal background results to: State Court Administration Court Interpreters Program 1111 E. Court Avenue Des Moines, IA 50319 Telephone: (515) 242-0191 Fax: (515) 725-8049 Email: john.goerdt@jb.state.ia.us (Version: 09-21-2006) American LegalNet, Inc. www.FormsWorkflow.com