PERSONAL CONFIDENTIAL INFORMATION FORM

FOR IOWA STATE JUDICIAL NOMINATING COMMISSION

Adopted for use beginning December, 2010

NOTE TO APPLICANTS: On advice of legal counsel, the Commission has determined

that 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 responses
to certain areas of inquiry. In the event the responses to the confidential application form
are the subject of a public records request, you may be asked in the future if you consent to
the release of all or a portion of the information provided.

In answering these questions, please repeat each question and place your answer immediately
beneath it. Please send your completed questionnaire to the Commission’s Secretary and each
member of the Commission as soon as possible since it is a prerequisite to consideration of your
candidacy. 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 resulted
from disciplinary action, administrative or legal, as a result.

5. Have you ever been arrested, charged, or held by federal, state, or other law enforcement
authorities for violation of any federal law or regulation, state law or regulation, county or
municipal law, regulation or ordinance? If so, give details and disposition. Do not include
traffic 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 Data
Questionnaire 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, bar
association, disciplinary committee, or other professional group that was dismissed or
resulted in a private admonition? If so, give the particulars.

8. Are you able to perform the essential functions of this position without a reasonable
accommodation? 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 Iowa
State Judiciary. If there is adverse information which you are reluctant to disclose to the
entire Commission, you may disclose it to the Chairman of the Commission, only, in a
separate writing who will disclose it to the other members of the Commission in nonpublic
session only if, in his opinion, that information has a bearing upon your qualifications for
the position you seek.

Dated
Signed

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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, records
or 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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