Criminal Records Check Authorization

As part of our pre-employment screening process, and to comply with state regulations, we will run a criminal records check through a qualified vendor. This notice is to inform you of our intentions of pulling the report as part of your application process. The results of the criminal records check, like all other application paperwork, will be kept with strict confidentiality. Your signature below authorizes us to pull the criminal history report. HDE also reserves the right to conduct a criminal records check on an employee during employment if: • A complaint or notification is given to HDE regarding abuse, harassment, a criminal offense, or other similar acts; • Or for any other justifiable reason, as determined by HDE management. This includes, but is not limited to, the employee has engaged in acts that may disqualify the employee from employment.

Full Legal Name
First Middle Last
Email*
Current Address
Street Address City State ZIP Code
Date of Birth
MM slash DD slash YYYY
SSN
DL or State ID Number
Sex
Have you been outside of Oregon for at least 60 consecutive days in the last 5 years?
- Yes
- No
Please list any other alias or names you have used
Out of Oregon Residence
Residence Start Date
MM slash DD slash YYYY
Residence End Date
MM slash DD slash YYYY
Address
City State / Province / Region Country
Residence Start Date
MM slash DD slash YYYY
Residence End Date
MM slash DD slash YYYY
Address
City State / Province / Region Country
Consent
I authorize HDE Home Care LLC to run my criminal records check
Type your name & today's date to confirm consent*

(503) 686-9079

Criminal Records Check Authorization

Out of Oregon Residence

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