Form 440-4912 "Criminal Background and Credit Check Authorization" - Oregon

What Is Form 440-4912?

This is a legal form that was released by the Oregon Department of Consumer and Business Services - a government authority operating within Oregon. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2016;
  • The latest edition provided by the Oregon Department of Consumer and Business Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form 440-4912 by clicking the link below or browse more documents and templates provided by the Oregon Department of Consumer and Business Services.

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Download Form 440-4912 "Criminal Background and Credit Check Authorization" - Oregon

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Oregon Department of Consumer and Business Services
Division of Financial Regulation
350 Winter St. NE, Rm. 410, Salem, Oregon 97301-3881
Mailing address: P.O. Box 14480, Salem, OR 97309-0405
503-378-4140  Fax: 503-947-7862
http://dfr.oregon.gov
CRIMINAL BACKGROUND AND CREDIT CHECK AUTHORIZATION
E
ach member, partner, officer, director, or principal; owner of 10 percent or more of the corporation; owner if applicant is
an entity other than a corporation; and proposed manager of the location must complete and sign the following:
First name:
Middle name:
Last name:
Name of company:
Home phone:
Office phone:
-
-
-
-
Home address:
Office street address:
City:
State:
ZIP:
City:
State:
ZIP:
Home mailing address, if different:
Office mailing address, if different:
City:
State:
ZIP:
City:
State:
ZIP:
Date of birth (mm/dd/yy):
/
/
Position or title:
Social Security number:
Email:
-
-
Driver license number and state:
Percentage of ownership:
%
ATTACH A RESUME OF THE LAST FIVE YEARS OF WORK EXPERIENCE
Have you been convicted of a felony?
No
Yes, explain:
Have you been convicted of a misdemeanor
for fraud, misrepresentation, or deceit?
No
Yes, explain:
Have you been the subject of an administrative
action in any state that resulted in civil penalties
or action taken against a license you held?
No
Yes, explain:
Have you had any entry of any money
judgments that are not paid in full?
No
Yes, explain:
Have you filed for voluntary or involuntary
bankruptcy protection?
No
Yes, explain:
I certify that the information I’ve provided is current and accurate as of the day it was signed and I understand that my
signature authorizes an investigative consumer report as defined in the Fair Credit Reporting Act (15 USC 1681 et seq.).
Signature
Date
440-4912 (5/16/COM)
Oregon Department of Consumer and Business Services
Division of Financial Regulation
350 Winter St. NE, Rm. 410, Salem, Oregon 97301-3881
Mailing address: P.O. Box 14480, Salem, OR 97309-0405
503-378-4140  Fax: 503-947-7862
http://dfr.oregon.gov
CRIMINAL BACKGROUND AND CREDIT CHECK AUTHORIZATION
E
ach member, partner, officer, director, or principal; owner of 10 percent or more of the corporation; owner if applicant is
an entity other than a corporation; and proposed manager of the location must complete and sign the following:
First name:
Middle name:
Last name:
Name of company:
Home phone:
Office phone:
-
-
-
-
Home address:
Office street address:
City:
State:
ZIP:
City:
State:
ZIP:
Home mailing address, if different:
Office mailing address, if different:
City:
State:
ZIP:
City:
State:
ZIP:
Date of birth (mm/dd/yy):
/
/
Position or title:
Social Security number:
Email:
-
-
Driver license number and state:
Percentage of ownership:
%
ATTACH A RESUME OF THE LAST FIVE YEARS OF WORK EXPERIENCE
Have you been convicted of a felony?
No
Yes, explain:
Have you been convicted of a misdemeanor
for fraud, misrepresentation, or deceit?
No
Yes, explain:
Have you been the subject of an administrative
action in any state that resulted in civil penalties
or action taken against a license you held?
No
Yes, explain:
Have you had any entry of any money
judgments that are not paid in full?
No
Yes, explain:
Have you filed for voluntary or involuntary
bankruptcy protection?
No
Yes, explain:
I certify that the information I’ve provided is current and accurate as of the day it was signed and I understand that my
signature authorizes an investigative consumer report as defined in the Fair Credit Reporting Act (15 USC 1681 et seq.).
Signature
Date
440-4912 (5/16/COM)