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Vulnerable Adult Check Request

  1. If yes, please provide contact information:
  2. Who to notify in case of emergency:
  3. I request that the Belle Plaine Police Department complete checks on the above named individual, as described above.

  4. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

  5. Leave This Blank:

  6. This field is not part of the form submission.