Criminal History Verification
Portland Public Schools
Shaded Area for District Use Only
NEW HIRE 2283 ATTACHED
RE-HIRE TSPC
FULL TIME PART TIME
CONTRACTOR: EMPLOYMENT/CONTRACT END DATE:
POSITION TITLE: SCHOOL/ DEPARTMENT:
SEND COPY OF CLEARANCE TO:
The person whose name appears below has been conditionally offered employment, contract, or assignment
to a contractor with Portland Public Schools and is subject to a criminal background investigation, which may
include a fingerprint records check. Portland Public Schools considers the applicants criminal history (if
any) in its entirety when being considered for a position and/or contract work.
The applicant is entitled to review his/her criminal history for inaccurate or incomplete information.
Name (Last) (First) (Middle)
Date of Birth
Driver License #
DL State
List Previous or Other Names Used
Social Security #
Place of Birth (State)
Gender
Height
Weight
Eyes
Hair
Contact Phone #
Citizenship
Street Address
City
State
Zip Code
List all previous resident addresses in the last 10 years or since your last background
check with Portland Public Schools. Attach a separate sheet if needed.
Date From
Date To
Complete Street Address
City/State
Zip
Current
Please complete both sides before submitting.
Clear Form
06/22/2018 09:34
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
offer.
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
employment terminated.
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: ___________
06/22/2018 09:34
Revised 06/22/2018
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