| The Humane Society of Central Oregon conducts a background, criminal and DMV record check for job applicants, new employees and volunteers. By your electronic signature, you authorize the Humane Society of Central Oregon and Criminal Information Services (CRIS) to obtain information about you and your history from various law enforcement agencies, courts and corrections agencies. Falsifying information on this form will disqualify you from volunteer or employment status. |
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| Fields highlighted in 'red' are required |
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| Last Name | First Name | Middle Name |
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| Other Last Name or Maiden Name | Other Last Name or Maiden Name | | |
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| Date of Birth | Drivers License Number | Social Security Number |
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| I have made no willful misrepresentations, omissions, or falsifications in any of the preceding answers. I am aware that should investigation disclose such misrepresentations, falsifications, or omissions in the information I have submitted in the application process, my application will be rejected. If, after acceptance for volunteer or employment status, subsequent investigations should disclose misrepresentation, falsification, or omission, it will be just cause for immediate dismissal. |
| By signing below, I give the Humane Society of Central Oregon and CRIS permission to verify any information I have provided. This authorization shall continues to be effective until revoked by me. A photocopy or facsimile of this consent shall be effective as the original. |
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| Signature | Signed Date |
| To save a printed copy of this application, use the 'Print' function within your browser. |
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