Criminal Background Check Request Form - Public Health Division, Oregon Medical Marijuana Program
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1
2PUBLIC HEALTH DIVISION
Oregon Medical Marijuana Program
Criminal Background Check Request Form
(Use mailing address noted below—do not send to OMMP)
Name (Last, first, middle)
Date of birth (mm/dd/yy)
Gender
Male
Female
All other names used (Last, first, middle; include maiden name)
Social Security number (SSN)*
Home mailing address (Street/apartment number)
Driver license, military or state
ID number:
City
State
ZIP
Home/message/phone
Home street address (if different than mailing address)
Cell phone
City
State
ZIP
Email address
Business name
Business city
MMD/MMPS number
*Providing your SSN is voluntary. The Oregon Health Authority (OHA) requests the Social Security
number solely to identify the person during a criminal records check.
Have you ever been charged, arrested and/or convicted of a controlled substance-related crime?
Yes
No
If yes, list all charges, arrests and/or convictions involving controlled substances and the outcome
regardless of how long ago. Please include the type of controlled substances involved.
Attach additional pages if needed.
Date
List each charge, arrest
Controlled
County
State
Outcome
(or estimate)
or conviction
substances
1.
2.
3.
1
3-24-16
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