Police Department Cell Phone

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BACKGROUND CHECK REQUEST

FORM

Reason for Request

Last Name First Name Middle Name

Street Address City State Zip Code

Race Gender Home Phone Cell Phone Work Phone

Height Weight Eyes Hair Criminal Record?

Yes No

Last 5 Numerals Of Social Security Number Driver’s License Number And State Date Of Birth

Place Of Birth (City/County/State/Country)

Any Other Names Used (Including Maiden Names)

If you answered yes to Criminal Record, list all charges, arrests and/or convictions and the outcome regardless of how long ago below. (Attach additional pages if needed.) Date (or estimate) List each charge, arrest or

conviction

Drug County State Outcome

1

2

3

4

5

6

7

8

9

10

I hereby certify that I am the above named individual and that the information provided is true and correct. I understand that a criminal records check will be completed on me. My signature below authorizes the Keizer Police Department to request and receive any juvenile, police, court or Page 2 of 2

investigation reports needed to complete this background check. In the event disqualifying information is discovered, and you disagree, you may contact Oregon State Police/Identification Service Section/Public Records Unit at 503-***-****.

I hereby release the City of Keizer, the Keizer Police Department and its officers, agents and elected officials from any and all liability or damage that may result from the background check and/or furnishing the information requested. I hereby release the City of Keizer, the Keizer Police Department and its officers, agents and elected officials from any and all claims should I be disqualified from volunteering as requested hereunder based on information of an adverse nature.

Printed Full Name Date

OFFICE USE ONLY

Criminal Record Found No Criminal Record Found Date: Initials

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