PUBLIC HEALTH DIVISION
Oregon Medical Marijuana Program
Criminal Background Check Request Form
(Use mailing address noted below—do not send to OMMP)
Name (Last, first, middle)
Date of birth (mm/dd/yy)
All other names used (Last, first, middle; include maiden name)
Social Security number (SSN)*
Home mailing address (Street/apartment number)
Driver license, military or state
Home street address (if different than mailing address)
*Providing your SSN is voluntary. The Oregon Health Authority (OHA) requests the Social Security
number solely to identify the person during a criminal records check.
Have you ever been charged, arrested and/or convicted of a controlled substance-related crime?
If yes, list all charges, arrests and/or convictions involving controlled substances and the outcome
regardless of how long ago. Please include the type of controlled substances involved.
Attach additional pages if needed.
List each charge, arrest