Form Msc 0301ad - Background Check Request Form Page 2
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Section 5: Completed by subject individual
15. Name: (last, first, middle)
16. Date of birth: 17. Gender:
18. Social Security or INS number: (voluntary)
M
F
19. All other names used: (Include maiden name.)
20. Driver’s license or ID card:
Number:
State:
22. Home or message phone:
21. Mailing address:
23. During the past 5 years, have you been outside
Street:
Apt:
Oregon 60 days or more in a row?
Yes
No
If yes, list where:
City:
From:
Until:
City/state/country:
State:
ZIP:
(month/year)
(month/year)
24. Street address: (if different than mailing address)
Street:
Apt:
City:
State:
ZIP:
25. Have you ever been charged, arrested and/or convicted of a crime?
Yes
No
If you answered yes, list all charges, arrests and/or convictions (adult and juvenile) and the outcome regardless of
how long ago. Attach additional pages if needed.
Date:
List each charge, arrest or conviction:
County:
State:
Outcome:
(or estimate)
1.
2.
3.
4.
5.
26. Provide a detailed explanation of all charges, arrests and convictions. (See “Questions to answer” in instructions.) This
information may directly affect the outcome of this background check. Add additional pages if needed.
I have read and understand the instructions for completing this form. I understand that a criminal records and
abuse check will be completed on me and that the information may be shared with the person listed in
section 1, box 1. My signature authorizes the Background Check Unit to request and receive any juvenile,
police, court or investigation reports needed to complete this background check. In the event potentially
disqualifying abuse is discovered, I will be notified at the address listed above and asked to provide additional
information. I certify the information I have provided is correct and complete. I understand that if I provide false
or incomplete information, my application may be closed or I may be denied the position. I understand the
check may be repeated during the time I hold this position.
27. Signature:
28. Date:
Page 2
MSC 0301AD (05/11)
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Parent category: Business