Background Check – Hearts with a Mission

Background Application

Step 1 of 2

Today's Date*
MM slash DD slash YYYY
Last Name*
First Name*
Middle Name*
Please List Other Names Used
Maiden or Alias
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Is Your Mailing Address Different?*
- Yes
- No
Mailing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
SSN #
(Optional)
DL # or State ID #*
State Issues*
Upload a Copy Of Your Driver's License
Max. file size: 100 MB.
Expiration Date*
MM slash DD slash YYYY
Mobile Phone*
Home Phone*
Email*
For identification purposes only, please provide FULL DOB:*

During the last five (5) years, have you been outside of Oregon for 60 days in a row or more?*
- Yes
- No
Residence 1
Start Date*
MM slash DD slash YYYY
End Date*
MM slash DD slash YYYY
City*
State*
Name(s) used at this residence*
NOTICE – BACKGROUND INVESTIGATION
Signature of SI Authorizing Background Check Process and Release of Information
My submission of this form with my signature authorizes the Background Check Unit (BCU) to initiate a criminal records check, which may include a national criminal records check requiring fingerprints, and to receive the results from Oregon State Police and the FBI. I understand that BCU will complete an abuse check on me. Any information from these checks may be shared with a qualified entity designee at the facility or licensing authority associated with this application.

My submission of this form with my signature authorizes BCU to request and receive any juvenile, police, court or investigation reports needed to complete this background check. In the event BCU discovers potentially disqualifying convictions or conditions, including abuse, BCU may notify me at the address or email I have given to request additional information.

My submission of this form with my signature authorizes BCU to release information given in this background check request or position information to any criminal justice agency or investigative body as needed for investigation, outstanding warrants or supervision requirements.

I authorize BCU to process this background check request. I certify that all statements I have made are currently accurate. I understand that I need to disclose any new information that occurs after I submit this form while the background check is still pending. 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 background check may be repeated any time while I hold the position for which this check is being done.
Name*
First Last
Date*
MM slash DD slash YYYY
Last Four Digits of SSN*
ACKNOWLEDGEMENT AND AUTHORIZATION*
I hereby authorize the Background Check Process and Release of Information.

Background Application

Step 1 of 2

Residence 1

NOTICE – BACKGROUND INVESTIGATION

Contact HWAM

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