Attachment_14_601.13_Vendor_Employee_Disclosure_Final.pdf

Confidential Page 1 of 2

Form 601.13

Oregon Lottery® Lottery Security Section 500 Airport Road SE PO Box 12649 Salem, OR 97309 503-540-1400

Name of Lottery Contact

Name of Company:

Business Address:

Your Work Number:

Email Address Your Position / Title / Role:

Name (Last, First, Middle) ________________________________________

Aliases _______________________________________________________

Home Address _________________________________________________

City __________________________________ State ______________

Zip Code __________________________ Phone #___________________

Date of Birth (MM/DD/YYYY)__________________

Social Security # ___________________________

Driver’s License # ___________________________

State DL Issued ___________________________

Sex: Female Male Other

Yes No

Yes No

Yes No

1. Have you ever been convicted at any time of any crime?

2. Do you have any Class “A” misdemeanor or felony charges pending against you?

3. Have you ever been convicted of violating any of the gambling laws of any state, country or local municipality?

4. Have you ever engaged in any type of unlawful gambling or gaming? Yes No

5.

If yes, explain:

Are you delinquent paying any Federal, State, Parish/County or other jurisdictional taxes? Yes No If yes, explain:

VENDOR EMPLOYEE DISCLOSURE FORM

VENDOR INFORMATION

PERSONAL BACKGROUND INFORMATION

Updated Oct. 2024

Confidential Page 2 of 2

If you answered yes to questions 1 or 2, please provide details in the space below. List all cases without exception, in any state, province, or jurisdiction.

Date Age Charge Location (City/State) Conviction Description

“I, the undersigned, upon oath, do hereby declare that the foregoing information is true, correct, and complete. I understand the information may be used to protect the public interest and to promote and assure the fairness, integrity, security, and honesty of the Oregon Lottery®. I understand that untruthful, incomplete, or misleading answers are cause for denial of the application and/or termination of any work or service agreement, or Lottery contract granted, and may be the subject of prosecution under ORS 162.065, 162.075, or 162.085. I acknowledge responsibility for excessive investigation costs incurred due to untruthful, incomplete, or misleading answers. I authorize the Office of the Director, Oregon State Lottery, to investigate or direct an investigation of any matter concerning me, as necessary, including, but not limited to financial records; financial sources; credit history; school records; child support enforcement records; criminal history records; Department of Motor Vehicle records; local, state, and federal tax records; and civil litigation records, as well as contact with listed and unlisted references. I acknowledge that I will consent to providing fingerprints, if asked to do so. Background investigations will be conducted by the Oregon State Police, Lottery Security Section”.

Name (Print): __________________________________________________________________________________________

Signature: ________________________________________________________________ Date: _________________

For Security Section Use Only:

Detective/Security Specialist: ___________________________ Date: _________________ Recommended: Yes No

Sergeant/Security Manager: ___________________________ Date: _________________

THE OREGON LOTTERY® RESERVES THE RIGHT TO REQUEST FULL DISCLOSURE AT ANY TIME DEEMED NECESSARY DURING AN INVESTIGATION.

To obtain a copy of your Identity History Summary check, also referred as “Criminal History Record”, visit:

https://www.fbi.gov/services/cjis/identity-history-summary-checks

To obtain more information on the Oregon State Police Criminal History check visit:

https://www.oregon.gov/osp/programs/cjis/Pages/CCH.aspx

Fingerprints are also required for all vendor employees. For those out of the area, the vendor employee may schedule a fingerprinting appointment at www.fieldprintoregon.com using the code "FPORLotteryVendDAS" along with their company name. FieldPrint has locations nationwide. If there are no offices nearby, fingerprinting may be done at a local law enforcement agency (three complete sets of print cards) and returned to Lottery Security with the completed Form 601.13.

If sending via Courier: If sending via US Mail If sending via email:

Oregon State Police Oregon State Police security.admins@lottery.oregon.gov Gaming Enforcement Division Gaming Enforcement Division Lottery Security Section Lottery Security Section 500 Airport Road SE PO Box 12649 Salem, OR 97301 Salem, OR 97309

*DISCLOSURE STATEMENT* (READ CAREFULLY)

Updated Oct. 2024 https://www.fbi.gov/services/cjis/identity-history-summary-checks https://www.oregon.gov/osp/programs/cjis/Pages/CCH.aspx mailto:security.admins@lottery.oregon.gov

Form 601.13