Get OR 440-4862 2009-2024

No Yes City State From Month/Year List all criminal charges for which you were convicted or pled guilty or no contest including dates of conviction or plea and jurisdiction attach separate sheet if necessary DCBS USE ONLY Criminal background check conducted LEDS Fingerprint Date Date submitted to OSP Name s of authorized designee s completing fitness determination Final fitness determination outcome 440-4862 9/09/COM Approved Denied. Department of Consumer Business Services Insurance Division 3 P. O. Box 14480 Salem OR 97309-0405 Phone 503-947-7981 Fax 503-378-4351 350 Winter St* NE Salem Oregon insurance. oregon*gov Criminal Records Request I understand that a criminal background check is required by the Oregon Department of Consumer and Business Services DCBS Insurance Division* I am voluntarily furnishing information for use in determining my fitness to be licensed under ORS 744. 001 or 744. 008. I understand that any or all information contained in my application for a license may be subject to verification by DCBS* I consent to the release of information related to my criminal background by law enforcement agencies to an authorized agent of DCBS* Applicant s signature Date signed Applicant s printed or typed name All previous names used by applicant Social Security number Date of birth Driver s license number and state During the last three years have you lived outside of Oregon for 60 or more consecutive days If yes list locations below. Department of Consumer Business Services Insurance Division 3 P. O. Box 14480 Salem OR 97309-0405 Phone 503-947-7981 Fax 503-378-4351 350 Winter St* NE Salem Oregon insurance. oregon*gov Criminal Records Request I understand that a criminal background check is required by the Oregon Department of Consumer and Business Services DCBS Insurance Division* I am voluntarily furnishing information for use in determining my fitness to be licensed under ORS 744. oregon*gov Criminal Records Request I understand that a criminal background check is required by the Oregon Department of Consumer and Business Services DCBS Insurance Division* I am voluntarily furnishing information for use in determining my fitness to be licensed under ORS 744. 001 or 744. 008. I understand that any or all information contained in my application for a license may be subject to verification by DCBS* I consent to the release of information related to my criminal background by law enforcement agencies to an authorized agent of DCBS* Applicant s signature Date signed Applicant s printed or typed name All previous names used by applicant Social Security number Date of birth Driver s license number and state During the last three years have you lived outside of Oregon for 60 or more consecutive days If yes list locations below. Department of Consumer Business Services Insurance Division 3 P. O. Box 14480 Salem OR 97309-0405 Phone 503-947-7981 Fax 503-378-4351 350 Winter St* NE Salem Oregon insurance. oregon*gov Criminal Records Request I understand that a criminal background check is required by the Oregon Department of Consumer and Business Services DCBS Insurance Division* I am voluntarily furnishing information for use in determining my fitness to be licensed under ORS 744. 001 or 744. 008. I understand that any or all information contained in my application for a license may be subject to verification by DCBS* I consent to the release of information related to my criminal background by law enforcement agencies to an authorized agent of DCBS* Applicant s signature Date signed Applicant s printed or typed name All previous names used by applicant Social Security number Date of birth Driver s license number and state During the last three years have you lived outside of Oregon for 60 or more consecutive days If yes list locations below. .