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Required Package

The Practical Nursing program at Black Hawk College requires the following services to be performed:

Background Check:Illinois Statewide Criminal Records
Iowa Statewide Criminal Records
County Criminal Records (all jurisdictions outside of IL & IA, 7 year history)
Nationwide Crime Database
Federal Criminal Records
Illinois Child Abuse Registry
Sexual Offender Registry
Healthcare Fraud & Abuse Registries
SSN / Address Validation
Price:$55.00


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Practical Nursing

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In order to obtain your Illinois Child Abuse Registry search, it is required that *THIS RELEASE FORM* is:

PRINTED (print this form off)

FILLED OUT (all fields must be completed)

UPLOADED (upload this form back onto site)

You cannot/will not be able to proceed with your order until this form has been completed and uploaded here.
* The form may be filled out electronically, but a wet signature is required *

If the correct form is not provided or filled out correctly, the Illinois Child Abuse item of your background check will be cancelled and you will be required to place a new Illinois Child Abuse order at the cost of $5.00.


Applicant Information
First Name*:  
Last Name*:
Middle Name:
Alias/Maiden Name 1:
Please Note: If you DO NOT have an alias name, leave this field blank. Only provide if you have used an alias within the last 7 years.
Alias/Maiden Name 2:
Please Note: If you DO NOT have an alias name, leave this field blank. Only provide if you have used an alias within the last 7 years.
Alias/Maiden Name 3:
Please Note: If you DO NOT have an alias name, leave this field blank. Only provide if you have used an alias within the last 7 years.
Social Security Number*:
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-

Please Note: If you have not been issued a valid U.S. SSN then enter all zeros (000-00-0000) instead.
Date of Birth*:
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(mm/dd/yyyy)
Gender*: Male        Female
Phone Number*: (111-111-1111)
E-Mail Address*:

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Current Residential Address
Address*:
City*:
State or U.S. Territory*:

For an international address, select "International" and select the foreign Country name below.
Country*:
Zip Code*:
ZIP Code Look Up Tool
Please Note: If you have an international address that does not require a Zip Code, please fill in "00000".
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