Ligutti Rural Community Support Program
National Catholic Rural Life Conference

PASSAGES Rural Life Associate Training Application

Name _________________________________________________Date ____________________

Mailing Address ___________________________________________ Zip Code _____________

County of Residence ____________________ County of Employment ____________________

Day Phone (____)______-______________ Evening Phone (____)______-______________

E-mail address ____________________ Do you have access to the internet? yesno

Birth Date ______/______/______

Occupation ____________________________ Employer ____________________________

Where or from whom did you find out about RLA training?

What experience, training, or education have you had that might help you as a Rural Life Associate?

What are some of your hobbies and interests?

Are you willing to undergo a criminal check?yesno

Do you have physical limitations on the type of activity you can do?

Emergency Contacts
A. Name:
B. Name:
Day Phone: Day Phone:
Evening Phone: Evening Phone:
Relationship to you: Relationship to you:

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For those seeking continuing education credit only: a $10 filing fee is payable at completion of training.
Underline profession: registered nurse, licensed mental health counselor, licensed social worker, licensed
marriage and family therapist
License number: SSN:
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Return application to Cece Arnold, National Catholic Rural Life Conference, 4625 Beaver Avenue, Des Moines, IA 50310
Phone: (515)270-2634 Fax: (515)270-9447

ncrlcca@mchsi.comwww.ncrlc.com/passages.html





Account Number ______________________________

STATE OF IOWA
NON-LAW ENFORCEMENT RECORD CHECK REQUEST
FORM A

To: Iowa Division of Criminal Investigation From: Attn: Cece Arnold
Bureau of Identification National Catholic Rural Life Conference
Wallace State Office Building 4625 Beaver Avenue
Des Moines, Iowa 50319 Des Moines, Iowa 50310-2199
(515) 281-5138 (voice - days) (515) 270-9447 (fax)
(515) 242-6876 (fax) (515)270-2634


I am requesting an IOWA CRIMINAL HISTORY check on:
(Type or Print Legibly)

REQUEST


________________________
Last Name
(mandatory)		 ________________________
First Name
(mandatory)		 ________________________
Middle Name
(recommended)
_____/_____/_____
Date of Birth
(mandatory)		 _______
Sex
(mandatory)		 _____-_____-_________
Social Security Number
(recommended)

________________________________________
Signature of Requester (Passages Director)

(There is a separate form “A” required for each last name submitted)

(DCI Use Only) RESULTS

As of ________________________ a Name and date of birth check revealed:
date

CCH record attached ____ No CCH record found ____

DCI initials ______

WAIVER

I hereby give permission for the above requesting official to conduct an Iowa criminal history record
check with the Division of Criminal Investigation. Any information maintained by the DCI may be
released as allowed by law.

________________________________
Signature
________________________________
Date


Form No. 595-1489 (4/99)






References for Rural Life Associate

Applicant’s Name: _________________________________________

Name of Reference A: _________________________________________

Relationship to you: _________________________________________

Day Phone: (____)______-______________

Evening Phone: (____)______-______________

Address of Reference (including zip code):

 _________________________________________
_________________________________________
_________________________________________



Name of Reference B: _________________________________________

Relationship to you: _________________________________________

Day Phone: (____)______-______________

Evening Phone: (____)______-______________

Address of Reference (including zip code):

 _________________________________________
_________________________________________
_________________________________________

Return to Cece Arnold, National Catholic Rural Life Conference,
4625 Beaver Avenue, Des Moines, IA 50310-2199
FAX: (515) 270-9447




If you preferrer to download the RLA Application Packet
just click on one of the links below.

PC Users RLA ApplicationPacket

Mac Users RLA ApplicationPacket

Both downloads come with 2 documents of the same thing but
made with 2 different programs Microsoft Word & AppleWorks.