Self-Disclosure Form - Oregon Department Of Public Safety Standards And Training
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1OREGON DEPARTMENT OF PUBLIC SAFETY STANDARDS AND TRAINING
NCIC Self-Disclosure Form
DPSST has obtained information that ___________________________ has an FBI number established.
Please review the NCIC information provided to you from your agency and self-disclose any entries
reported. This information is necessary to determine your eligibility for training and/or certification.
Type of Entry
Agency
City, State
Applicant
Arrest
Conviction
Other ________________________
Date:
Charge or reason for entry:
Statute/Arrest Code:
Disposition:
Type of Entry
Agency
City, State
Applicant
Arrest
Conviction
Other ________________________
Date:
Charge or reason for entry:
Statute/Arrest Code:
Disposition:
Type of Entry
Agency
City, State
Applicant
Arrest
Conviction
Other ________________________
Date:
Charge or reason for entry:
Statute/Arrest Code:
Disposition:
Type of Entry
Agency
City, State
Applicant
Arrest
Conviction
Other ________________________
Date:
Charge or reason for entry:
Statute/Arrest Code:
Disposition:
Yes
No The information contained on this form is true and correct to the best of my knowledge. I understand that
falsification of this document makes my certification(s) subject to denial or revocation under ORS 181.662 and OAR
259-008-0070.
Applicant’s Signature______________________________________________ Date ____________________________
AGENCY HEAD or AUTHORIZED REPRESENTATIVE: I certify that the information entered on this form has been
verified and is substantiated by records maintained by this department. I understand that falsification of this document
makes my certification(s) subject to denial or revocation under ORS 181.662 and OAR 259-008-0070.
Signature _____
Title _______________________________________
Agency Head or Authorized Representative
Printed Name
Date ________________________________________
Revised 9-9-11
Dept. of Public Safety Standards & Training
4190 Aumsville Hwy. SE, Salem, OR 97317
Phone: 503-378-2100, Fax: 503-378-4600
Web Page:
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