REQUEST FOR CRIMINAL HISTORY INFORMATION
ORS 181.155 AND 181.560
PAGE ONE OF TWO
Client: Best Western Inn at the MeadowsTo be completed and sent to:
Contact Person: Steve LeePI Services LLC
1215 N. Hayden Meadows Dr.POBOX 157
Portland, OR97217Beaverton, OR97075
Phone:503-286-9600503-643-4274 / fax-643-5474
Fax:503-286-8020(return results via email)www. pi-info.com
Email:
PLEASE TYPE or PRINT CLEARLY
Full Name: ______
LastFirstMiddle
Maiden/Former Legal Name**: ______(if used in the past ten years)
(**Additional charges apply for additional names searched)
Date of Birth: ____/____/____ Social Sec#:_____-____-_____ Phone:_____-______-______
(#not needed for OR & WA)
Driver’s License #: ______State: ______
Current Address: ______
______First time background check for Best Western, checking 10 year address history.
______One year renewal, only checking last years address history.
LISTALLCITIES, STATES AND DATES YOU HAVE RESIDED WITHIN THE PAST TEN YEARS.
CITY & COUNTYSTATEDATE_____
Portland-Multnomah EXAMPLEOregon EXAMPLE April 2005to April 2015
______
______
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______
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Applicant’s signatureI swear the above information is true and correct. Date Page 1 of 2
REQUEST FOR CRIMINAL HISTORY INFORMATION
ORS 181.155 AND 181.560
PAGE TWO OF TWO
Have you been convicted of a crime in the past 10 years? Yes _____ No _____
If yes, when and where did the conviction take place?
______
______
______
Check off States wanting background checks completed in.
______Oregon Circuit Statewide $20.00 **Price is for each name searched
______Washington Statewide $25.00 **Price is for each name searched
______Idaho Statewide $20.00 **Price is for each name searched
______NW Statewide OR, WA, ID 45.00 ** Price is for each name searched
______Other States (ListCounty and State – Call for price $___.00 **
______
Payment Options:
[ ]: Pay with a credit card on our website,visit the make a payment page.
After payment is made fax, email or mail your form to our office.
Prepayment confirmation #______
[ ]: Send this form with a check, cash or money order to:
PI Services POBOX 157Beaverton, OR97075
[ ]: We will invoice you. Fax, email or mail your form to our office.
Please make sure we have all your above contact information correct.
Payment is duewith in 30 days of invoice.
______
Applicant’s Signature I swear the above information is true and correct. DatePage 2 of 2
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To be competed by PI Services Date received:______
CRIMINAL RECORD FOUND: No / Yes (If yes, see attacheddockets sheet(s) with _____ record(s) found)
Date of record search: ______Results sent to Client via: Fax / Email / Mail