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Criminal Background Check Request Form - Public Health Division, Oregon Medical Marijuana Program Page 2

During the last five years, have you been outside of Oregon for 60 days or more in a row?

Yes

If yes, complete the following for each residence in the past five years.

Attach additional pages if needed.

Date (mm/dd/yy)

Name(s) used at

City

State

Country

this residence

Start

End

By signing below, I hereby certify that I am the person listed and that the information on this form is

complete and correct. I understand that I will need to have a national criminal records check including

fingerprints. My signature authorizes the OMMP program, in partnership with the Department of

Human Services/Oregon Health Authority Background Check Unit, to request and receive any

juvenile, police, court or investigation reports needed to complete this background check. If

information is found that disqualifies me, I will receive information about how to challenge the

background check information. I understand that if I provide false or incomplete information, my

application may be returned as incomplete or denied. I understand that the background check may be

repeated during the time the dispensary or processing site is registered.

Signature:

Date:

When fingerprints are electronically transmitted without a fingerprint card, please attach a completed

copy of the “Request for Transmission of Electronic Regulatory Fingerprints” form, and note the

following information:

Name of transmitting agency:

Date printed:

If you have fingerprint‐related questions, please call the Background Check Unit at 503‐378‐5470 (option

6); toll free at 1‐888‐272‐5545 (option 6); or by email at bcu.info@state.or.us.

Mail this completed form and fingerprint card (unless electronically transmitted) to:

DHS/OHA Background Check Unit

PO Box 14870

Salem OR 97309‐5066

Oregon Medical Marijuana Program, P.O. Box 14116, Portland, OR 97293-0116

Phone: 1-855-244-9580 |

3-24-16

Criminal Background Check Request Form - Public Health Division, Oregon Medical Marijuana Program Page 2