COPY OF OWN RECORD REQUEST

This form is to be used ONLY when requesting a copy of your own Oregon Criminal History information or clearance letter.   This form may be copied.

NAME: ________________________________________________________________
                                     Last                                              First                                   Middle

OTHER NAMES USED:____________________________________________________

DATE OF BIRTH:_________ /_________/_________
                                     month              day              year

SOCIAL SECURITY NUMBER:  (optional) _________ - _________ - __________

YOUR MAILING ADDRESS:________________________________________________
                                                                                        Street or P.O. Box

______________________________________________________________________
                 City                                       State                                         Zip Code

______________________________
                       Country

TELEPHONE (______)________________________________
 

MY CHECK OR MONEY ORDER, PAYABLE TO OREGON STATE POLICE, IS INCLUDED FOR THIS SERVICE AS FOLLOWS:

• COPY OF OWN RECORD ($12.00)           ____________

  PLEASE NOTARIZE RESPONSE ($5.00) ____________

                                     TOTAL INCLUDED  ____________

**Your fingerprint card will be returned with your response.