Criminal Record Expungement Intake Form

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Once you fill out this form, someone will reach out to you with a copy of your Oregon criminal record. The email will go over the eligible charges on your record. If you would prefer, you can come into one of our clinics. You do not need to fill out the intake form to come to one of our clinics.

Legal Name (First, Middle, Last) *

Date of birth *

YYYY

Any aliases or prior names used

Phone *

Email *

Address *

City *

State *

Zip Code *

Which of the following best describes your racial or ethnic identity? *

African American or Black

African

Asian

Latino / Hispanic

Middle Eastern

Native American / Alaska Native

Native Hawaiin

Pacific Islander

Slavic

White

Decline to Answer

Other:

How did you hear about the CLEAR Clinic? *

Google/Online Search/ Internet

Friend/Family/Word of mouth

Court

School

Other:

Submit

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