Sjnc Confidential Information Form-1

8/8/2019 Sjnc Confidential Information Form-1

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PERSONAL CONFIDENTIAL INFORMATION FORMFOR IOWA STATE JUDICIAL NOMINATING COMMISSION

Adopted for use beginning December, 2010

NOTE TO APPLICANTS: On advice of legal counsel, the Commission has determinedthat the responses to the questions listed below will or may disclose information that is

confidential under state or federal law, and that confidentiality will foster candid responsesto certain areas of inquiry. In the event the responses to the confidential application formare the subject of a public records request, you may be asked in the future if you consent tothe release of all or a portion of the information provided.In answering these questions, please repeat each question and place your answer immediatelybeneath it. Please send your completed questionnaire to the Commissions Secretary and eachmember of the Commission as soon as possible since it is a prerequisite to consideration of yourcandidacy. A recent photo may be attached to assist the Commission, if you choose.

l. State your full name:

2. State your full office and home addresses, zip code, telephone numbers and area codes

(name of law firm if applicable):

3. List the dates and places of your residency:

4. If you served in the military and received something other than an Honorable Discharge,please give all particulars in connection therewith and whether such discharge resultedfrom disciplinary action, administrative or legal, as a result.

5. Have you ever been arrested, charged, or held by federal, state, or other law enforcementauthorities for violation of any federal law or regulation, state law or regulation, county ormunicipal law, regulation or ordinance? If so, give details and disposition. Do not includetraffic violations for which a fine of $250 or less was imposed, unless you were arrested.Please include all information not disclosed in response to Question 15 on the Personal DataQuestionnaire form, including deferred judgments that have been expunged.

6. Have you ever been listed on a child or dependent adult abuse registry?

7. Have you ever been the subject of a complaint to, any court, administrative agency, barassociation, disciplinary committee, or other professional group that was dismissed orresulted in a private admonition? If so, give the particulars.

8. Are you able to perform the essential functions of this position without a reasonableaccommodation? If you answered no, please explain.

9. State any other information which may reflect adversely on you, or which you believe

should be disclosed in connection with consideration of you for nomination for the IowaState Judiciary. If there is adverse information which you are reluctant to disclose to theentire Commission, you may disclose it to the Chairman of the Commission, only, in aseparate writing who will disclose it to the other members of the Commission in nonpublicsession only if, in his opinion, that information has a bearing upon your qualifications forthe position you seek.

DatedSigned

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WAIVER OF CONFIDENTIALITY

The undersigned applicant hereby waives the benefits of any statute, rule or regulation

prescribing confidentiality of records of any court, administrative, or disciplinary Committee of

any State; and does authorize and request every person, firm, company, corporation,

governmental agency, court, association or institution having control of any documents, recordsor other information pertaining to the undersigned, to furnish to the State Judicial Nominating

Commission any such information, including documents, records, bar association files regarding

charges or complaints filed against the undersigned, formal or informal, pending or closed, or

any other pertinent data, and to permit the State Judicial Nominating Commission or any of its

members, agents or representatives to inspect and make copies of such documents, records, and

other information. The undersigned does hereby release and discharge the State Judicial

Nominating Commission, its individual members as now and hereafter constituted, their agents

and representatives, and any other person so furnishing information from any and all liability of

every nature and kind arising out of the furnishing of information to or investigation out of the

release and use of information so provided concerning the applicant.

/S/____________________________________

Date: __________________________________

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DISCLOSURE AND RELEASE

This is to notify you that a background investigation will be conducted through the NCIC

network.

By signing the release below, I hereby authorize the Iowa Judicial Branch to contact any and all

corporations, former employers, educational institutions, law enforcement agencies, city, state,county, and federal courts, military services to release information about my background

including, but not limited to, information about employment, education, driving record, criminal

record and general public records history to the Iowa Judicial Branch.

I release from all liability all persons, companies, schools supplying such information. I

indemnify the Iowa Judicial Branch against any liability, which may result from making such

requests. This release shall remain in effect for the length of my employment. I understand and I

may have a right to request additional disclosures regarding the nature and scope of the

investigation.

I believe to the best of my knowledge that all information I have provided is accurate, true and

correct and that I fully understand the terms of this release.

(Please print)

Name: _______________________________________________________________________

Other names used: ______________________________________________________________

Address: ______________________________________________________________________

City/State/Zip: _________________________________________________________________

Date received degree (if applicable): ________________________________________________

Social Security Number: ______________________ Birth Date: ________________________

Driver's License Number & State: __________________________________________________

______________________________________________________________________________

(Signature of Applicant)

______________________________________________________________________________

(Please print name of Applicant)

________________________________________

(Date)

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Documents

Sjnc Confidential Information Form-1