Criminal History Verification Of Applicants Form - Oregon Department Of Education

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Oregon Department of Education

Office of Finance and Administration

CRIMINAL HISTORY

Public Service Building

Pupil Transportation and Fingerprinting

VERIFICATION OF APPLICANTS

255 Capitol Street NE

503-947-5887

Salem, Oregon 97310

THIS FORM MUST BE ENCLOSED WITH THE 581-2281-N SCHOOL/DISTRICT COVER FORM AND A CHECK FOR $5.00 PER APPLICANT.

ALL DOCUMENTS MUST BE MAILED TOGETHER TO THE DEPARTMENT OF EDUCATION.

Please type or print clearly.

As Appears on License

Name: ______________________________ _________________________ _________________________ Date of Birth:______________ Sex:

(Last Name)

(First Name)

(Middle Name)

MM/DD/YY

List Other Names Previously Used:

(includes Maiden Name)

Social Security No.:

Driver License/Identification Card No.:

Providing your social security number on this form is voluntary. If you choose not to disclose the social security number, this will not be a basis for denial

of employment or any rights, services or benefits to which you are otherwise entitled. If you do provide the number the Oregon State Police will use it as

an additional identifier to search for any criminal record you may have. Your social security number will be used as stated above. State and federal laws

protect the privacy of your records.

Mailing Address:

Full Street Address/Post Office Box

City:

State:

Zip + 4:

A. Have you EVER been convicted of a sex-related crime?

Yes

If yes, was the conviction in Oregon or another state? (Please specify if another state.) State:

If yes, did the crime involve force or minors?

Yes

B. Have you EVER been convicted of a crime involving violence or threat of violence?

Yes

If yes, was the conviction in Oregon or another state? (Please specify if another state.) State:

C. Have you EVER been convicted of a crime involving criminal activity in drugs or alcoholic beverages?

Yes

If yes, was the conviction in Oregon or another state? (Please specify if another state.) State:

D. Have you EVER been convicted of any other crime except a minor traffic violation?(Includes Traffic Crimes)

Yes

E. Have you been arrested within the last three years for a crime for which there has not yet been an acquittal or dismissal?

Yes

Advisory: A check of the applicant's criminal history will be made by the Oregon Department of Education to verify the responses to the preceding

questions.

I hereby grant to the Oregon Department of Education permission to check civil or criminal records to verify any statement made on this form.

Regardless of whether the applicant grants consent, the Oregon Department of Education will conduct a criminal offender record check of applicants for

the position of school bus driver, volunteer, or other prospective school employees working with or around children. The applicant is entitled to review

his/her criminal history for inaccurate or incomplete information. Discrimination by an employer on the basis of arrest records alone may violate federal

civil rights law. The applicant may obtain further information concerning the applicant's rights by contacting the Bureau of Labor and Industries, Civil

Rights Division, State Office Building, Suite 1070, Portland, Oregon 97232, telephone (503) 731-4075.

I acknowledge reading and the receipt of this notice.

Applicant's Signature:

Date:

Form 581-2282-M (Rev. 4/13)

This Form may be reproduced locally without change.