ESCROW CRIMINAL RECORDS CHECK APPLICATION
Revised 2/2021
Page 1 of 3
Real Estate Agency
530 Center St. NE, Ste 100
Salem OR 97301
Phone: (503) 378-4170
www.oregon.gov/rea
ESCROW CRIMINAL RECORDS CHECK $47 - 0430
Read the application and accompanying instructions carefully. Answer ALL questions completely. If additional
space is needed for an answer, attach a separate sheet indicating the section or number to which the information
applies. Date and sign any attached sheets. You will be notified if we need additional information.
Mail this completed form to the Agency at the address above, along with:
a) One completed fingerprint card that meets FBI processing standards.
b) Your resume detailing your experience in the administration of escrows, including names of former
employers, dates employed and duties.
c) Materials listed in Section D-4 if you answered “yes” to any questions in Sections D-1 through D-3.
Upon receipt of all the required documents, the Agency will email the escrow organization with instructions on how to
pay the required fee in eLicense.
SECTION A ESCROW AGENT INFORMATION
Name of Escrow Agent
Main Office Address
Main Office Phone
SECTION B YOUR RELATIONSHIP TO ESCROW AGENT
Individual owner of escrow agent with more
Corporate Officer in charge of escrow
Individual in charge of escrow
than 5% ownership interest
operations operations
SECTION C YOUR INFORMATION
Legal last name
Legal first name
Legal middle name
Personal mailing address
City, state, zip
Residence street address, city, state, zip (if different than above)
E-Mail Address
List all states lived in for past 10 years
List any other names ever used, including nicknames, aliases, maiden, prior married, etc.
Social Security No
.
Daytime phone number
Alternate phone number
Save As
Reset Form
ESCROW CRIMINAL RECORDS CHECK APPLICATION, continued
Page 2 of 3
ESCROW CRIMINAL RECORDS CHECK $47 - 0430
SECTION D BACKGROUND QUESTIONS
Criminal Disclosure
a) Have you ever been convicted* of any felony or misdemeanor criminal offense? **
b) Are you currently under investigation, indictment, awaiting trial, verdict or sentencing in any
criminal proceeding? **
c) Do you have any criminal arrest or citation, which has yet to be adjudicated? **
d) Are you a fugitive from justice?
e) Are you presently on parole or probation or paying any restitution or fine?
* “Convicted” includes a guilty or “no contest” plea, verdict of guilty by a judge or jury, or a forfeiture of
bail. All convictions must be disclosed, even if they were later dismissed, a diversion program
completed, or occurred when a minor.
** Include major traffic violations such as DUI, reckless driving, or driving while suspended or uninsured.
Yes No
1
Regulatory Disclosure
a) Have you ever had a trade, occupation or professional license (other than your driver’s license)
or registration fined, reprimanded, suspended, involuntarily terminated, revoked or otherwise
subject to any type of disciplinary action whether or not you were ultimately sanctioned? *
b) Have you ever surrendered or allowed to expire a professional license (other than your driver’s
license) or registration, or were permitted to resign after allegations were made against you, in
connection with or while under investigation, or while an action was pending? *
c) Are you currently under investigation, involved in a hearing, trial, administrative proceeding or
other action by the authority that issued the professional license or registration? *
d) Have you ever received an adverse decision or judgment against you in a criminal, civil, or
administrative action related to your business or professional activities? *
e) Have you ever acted, or attempted to act, in a regulated profession at a time when you were
not licensed or legally authorized? *
f) Have you ever had an application for a license or registration denied or issued with restrictions
or limitations? *
g) Have you ever been terminated from any employment for theft, fraud, or dishonesty?
* Include if you were a participant in a partnership, corporation, or other business entity that was the
subject of such action.
Yes No
2
Civil & Financial Disclosure
a) Have you ever received an adverse decision or judgment against you related to a real property
matter? *
b) Do you have any unsatisfied judgments or liens against you? *
c) Are you currently in arrears for child support?
d) Have you filed bankruptcy (personal or professional) in the past ten years? *
e) Are you currently awaiting trial or a Court verdict in any civil proceeding (not including divorce
or child custody)? *
* Include if you were a participant in a partnership, corporation, or other business entity that was subject
to such action.
Yes No
3
4
If you answered “yes” to any of the questions in this section, you must send the following with this application:
a) A detailed, written statement of explanation. Include dates, location, involved agencies and/or courts,
nature, circumstances and disposition. Date and sign your written statement.
b) Current, original letters from at least 3 persons (not relatives) attesting to your good character and
reputation. Letters must be signed, dated, and include contact information. Form letters are unacceptable.
c) If the incident(s) occurred in the past ten years, copies of official documents that confirm the nature and
current status or disposition. Documents not required for bankruptcy (still must submit a, b & c above).
You may attach additional information for consideration during the criminal records check process.
YOU’RE NOT DONE YET – PLEASE GO ON TO PAGE 3!
ESCROW CRIMINAL RECORDS CHECK APPLICATION, continued
Page 3 of 3
ESCROW CRIMINAL RECORDS CHECK $47 - 0430
SECTION E ACKNOWLEDGEMENT, CONSENT & SIGNATURE
Read this section carefully before signing below.
I understand it is my responsibility to read the accompanying instructions thoroughly and to submit a complete
application, including required documents and fees. If the information developed by the Agency requires the
submission of additional information, it is my responsibility, upon request by the Agency, to provide the requested
information. I further understand that failure to do so may cause my application to be considered incomplete which
will result in termination of the application.
I understand and acknowledge that submission of this signed application authorizes the Agency to process the
included fingerprint cards through and receive information from the Oregon State Police and the Federal Bureau of
Investigations relating to any arrest or criminal history information of record.
If I have successfully completed the criminal records check process and review but the escrow agent doesn’t
successfully complete the licensing application process or application for change in ownership or change to
corporate officers or individuals in charge of escrow operations within twelve months from the date of the
successfully completed criminal records check process and review, the successfully completed criminal records
check process and review is no longer valid.
I certify that my answers on this application and accompanying documents are true, correct, and complete to the
best of my knowledge. Any information found to be knowingly or negligently misrepresented, incomplete or
inaccurate, will be grounds for denial of criminal records check clearance. Failure to disclose pertinent information
will cause substantial delays in the process.
Original Signature of Applicant
Date