Criminal History Verification
Portland Public Schools
Warning: Falsely responding to any of the questions listed below may prohibit your
employment. If you have any questions, be certain you ask before you
submit this form. Do not assume that your conviction records have
been automatically sealed, removed, or expunged. If you have any
question about your record it is better to answer yes and explain on a
separate sheet of paper. A positive response to the questions below does
not automatically exclude you from working with Portland Public Schools.
Failure to disclose fully may have an adverse effect on an employment
A. Are you currently on Parole or Probation? Yes No
If yes, please call Security Services at (503) 916-3000 before you apply.
B. Have you EVER been convicted of ANY crime? Yes No
If yes, state the charge(s), city, state, date of arrest, and date of conviction.
C. Do you have any pending or unresolved criminal charges? Yes No
If yes, state the charge(s), city, state, date of arrest.
D. Have you had a background check conducted by Portland Public Schools in the
past? Yes No
If yes, provide the approximate date of your last back background check.
Providing your social security number on this form is mandatory. This will be used for the background and
fingerprint check, which requires a social security number. The privacy act of 1974 (PL.93-579) requires
that government agencies inform individuals, whether such disclosure is mandatory and the basis of
authority for such solicitation, and how it will be used. All employees and contractors for the school district
are subject by law to a criminal records check (OAR 581-021-0500). Subject individuals who have been
convicted of any crime listed in ORS 342.143 or the substantial equivalent in another jurisdiction or in
Oregon under a different statutory name or number shall be refused continued employment and or have
By signing below, I verify that the information I provided on this document is true and accurate to the best of
my knowledge. I also understand that any false statement may be sufficient to deny me from any employment
with Portland Public Schools. I verify that I have read the warning statement above and understand
employment is based on a thorough review of any criminal history.
Applicant Signature: ______________________________ Date: ___________