SECTION 1 To Be Completed by Applicant
Full Name:
Additional Names
Date of Birth
Applicant Signature
Date
I have been informed that to be allowed access to areas associated with Criminal Justice Information Systems (CJIS), a state and national
fingerprint
-based background check is required. I understand that the existence of a criminal record will not necessar
ily disqualify me for
employment, contract work, or being a volunteer; however, it may impact what areas I will be allowed to
access. Further
, I understand
that if there is any question regarding the results of the fingerprint
-based background check, I may
contact the Oregon State Police CJIS
Division for additional information.
SECTION 2
To Be Completed by Agency
Applicant ORI
Sworn - Police Officer
Flag 8801
☐
Sworn - Corrections
Flag 8802
☐
Sworn - Reserve
Flag 8803
☐
Non-Sworn
Flag 8804
☐
SECTION 3
Manager/Agency Contact Information
Th
e manager/CJIS Representative listed below
will receive the results of this background check via email once the transaction has been
successfully processed.
Agency
ORI
Name
Phone
Email
Manager/CJIS Representative Signature
Date
The applicant identified above is required to have access to a CJIS security area under my direction. By submitting this form with the
applicant’s fingerprints within 30 days of initially appointing the applicant, I am complying with the CJIS Security policy r
equiremen
t for
this facility and as directed in section 5.12.1.1 of the CJIS Security Policy and the State CSO or their designee. I affirm that this CJIS Security
Clearance Request is not being submitted for the purposes of conducting an employment background check.
SECTION 4
Application Submission
Please submit this form and fingerprints to the Oregon State Police CJIS Division within 30 days of the applicant being appointed to their
position All fields on this form are required. Incomplete forms will not be processed and purged as incomplete transactions after 30 days of
the initial submission.
Mail
: Oregon State Police CJIS Division 3565 Trelstad Ave SE Salem, OR 97317
Fax: 503-378-2121
Email: OSP.CJIS@osp.oregon.gov
OSP - Criminal Justice Information Services Security Clearance Background Request 2024-06
Criminal Justice Information Systems
Security Clearance Application Request
