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

______

______

______

______

______

______

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