Form Msc 301 Qed - Background Check Request Form Page 5
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7SHARED SERVICES
Background Check Unit
Background Check Request
Instructions for Subject Individual (SI)
Read all of the instructions before completing the form.
As the subject of this background check, you are referred to in these instructions as the subject
individual (SI). The qualified entity (QE) listed in box 1 may be your employer or local branch. The
authorized designee (AD) or contact person (CP) has received training from the Department of
Human Services Background Check Unit (BCU) for background checks.
Section 2 — You, the SI, completes this section.
10.
Type or print your complete name.
11.
The disclosure of your Social Security Number (SSN) is optonal. The BCU requests the
SSN or INS number solely for the purpose of positively identifying you during the
background check process. If you do not provide a SSN, the BCU may request fingerprints
to confirm identity.
12.
Enter your date of birth (mm/dd/yyyy).
13.
Enter your email address. The BCU will use your email for any correspondence regarding
our background check unless you indicate to use your mailing address (see #17).
14.
Check the box for your gender.
15.
Enter your driver license or state ID, listing the state and the number.
16.
Type or print all aliases or other names you have ever used.
17.
Check this box only if you prefer to have correspondence from BCU sent to your mailing
address rather than email.
18.
Type or print your residence address. If you have a mailing address that is different from
your residence, type or print it.
19.
Type or print the phone numbers where you can be reached.
20.
If you have lived outside of Oregon in the past 5 years for more than 60 days in a row,
check the “yes” box and provide details of your previous residences. If you have lived in
Oregon for the entire past 5 years, check the “no” box and go to #21.
21.
Provide information on your criminal history. If you have never been arrested, charged, or
convicted, check the “no” box and go to #22.
Disclose all criminal history — You must accurately and completely disclose all history
(adult and juvenile) regardless of how long ago it happened. This includes all felonies,
misdemeanors, probation violations and failures to appear. If you fail to list any part of your
history, your application may be closed or you may be denied due to false statement. Any
serious traffic offense such as reckless driving, driving under the influence of intoxicants
(DUII) and driving while suspended (DWS), must be listed. Failure to appear, even for a
minor traffic violation, must be listed. If you are not sure if something should be listed, you
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MSC 301 QED (10/12)
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