Background Check Form – Rogue Valley Mentoring

Background Check FormBella Feldman2018-09-10T20:12:49-07:00

Background Check Questionnaire

Name (Last, First, Middle) *
Date of birth (mm/dd/yyyy) *
Driver's License (State)
Driver's License Number
Aliases/other names used
Social Security Number (Optional: if you are already in the background check system, you may not need to submit fingerprints again if you provide this number):

Oregon Residency

Have you lived outside of Oregon in the past 5 years for a period of 60 days or more? *
YesNo
Details of non-Oregon residency
If you have lived outside of Oregon in the past 5 years for 60 or more days, list the dates (From and To) , and the City/State/Zip Code of each place you have lived. List one location per line.

Contact info

Email address *
Address *
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Check this box if your prefer communication be sent via postal service, rather than email
Mail paper documents
Mailing Address (if different)
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Mobile Phone
Alternate Phone

Criminal Record Info (if applicable)

Date
Charge, arrest or conviction:
Charged or dismissed:
City:
County:
State:
Date
Charge, arrest, or conviction:
Charged or dismissed::
City:
County:
State:

Agreement

By checking this box, you are electronically signing: *
I agree that all info on this form is correct.

Verification

Please enter any two digits *Example: 12
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