Form Msc 301 Qed - Background Check Request Form Page 2
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7Section 1 — To be completed by a QED (continued)
8. Type(s) of documents checked to verify identity (check all that apply):
Driver’s license or state ID
Social Security card
Passport
Other:
Initials of person checking ID:
9: Worksite locations/address for this position (enter all if multiple):
Section 2 — To be completed by the SI
10. Individual name:
(Last/First/Middle)
11. Social Security number (optional):
12. Date of birth (mm/dd/yyyy):
13. Email address:
14. Gender:
Female
Male
15. Driver’s license ID:
State:
Number:
16. Aliases/other names used:
17.
Check only if you prefer correspondence be sent to your residential or mailing address
(rather than an email address).
18. Residence street address:
City:
State
ZIP code:
Mailing address:
Same as residence
City:
State
ZIP code:
19. Home phone:
Mobile phone:
20. During the last five (5) years, have you been outside of Oregon for 60 days in a row or more?
Yes
No If yes, complete the following for each residence in the past 5 years:
Date (mm/dd/yy)
Name(s) used at
City:
State: Country:
Start:
End:
this residence:
Page 2 of 7
MSC 301 QED (10/12)
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