Criminal Background//Credit Check Form Important – to be completed by employer or recruiter1. Photocopy 2 pieces of identification, 1 piece must be government issued with candidate’s picture and signature. 2. Scan these pages and email to info@referencesandmoreservices.com or fax to 1-866-665-4759 3. When photocopying ID, ensure it is clear and can be read.Services Ordered: Criminal Background Check Credit Bureau Inquiry Identification Verification of EmployeeCompany Client Code/Name/Location (Optional) Witness Email Address I have examined the identification of the person below and am satisfied that the person depicted on the photo identification is one and the same First Last Witness SignatureHave you ever been convicted of a criminal offence? Yes No If “Yes” please provide details below. Do not declare the following: Absolute discharges or Conditional Discharges, pursuant to the Criminal Code, section 730. Any charges for which you have received a Pardon, pursuant to the Criminal Records Act. Any offences while you were a “young person” (12 years old but less than 18 years old), pursuant to the Youth Criminal Justice Act. Any charges for which you were not convicted, for example, charges that were withdrawn, dismissed, etc. Any provincial or municipal offences. Any charges dealt with outside of Canada.Offence Date Location Penalty Offence Date Location Penalty Candidate Consent Candidate First Name Middle Name Last Name Maiden Name(s) / Alias (Other Names) Birth Date Month Day Year Gender Male Female Present Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country TelephonePrevious Address (if present address is less than 5 years) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Place of Birth (Town, Prov., Country or Hospital) Email Address I have applied to* for employment. Part of the screening process includes a criminal history check which searches the RCMP Canadian Police Information Centre (CPIC) database. References and More Services and/or its agents conduct these investigations on behalf of THE AFOREMENTIONED COMPANY. I hereby consent and authorize a Canadian Police Department to search for and disclose on my behalf to References and More Services and/or its agents who is requesting the criminal history check on behalf of THE AFOREMENTIONED COMPANY the fact that records may exist on me and are registered on the CPIC database. I acknowledge that such records may include information relating to criminal convictions under federal legislation for which a pardon has not been granted. I authorize References and More Services and/or its agents to release all information obtained to THE AFOREMENTIONED COMPANY and hold harmless References and More Services and/or its agents upon the release of this information or its findings to THE AFOREMENTIONED COMPANY. The Applicant consents to the release of the information contained in the application and results of the criminal reference check being disclosed to the necessary third party for the purposes of THE AFOREMENTIONED COMPANY business. I understand that failing to provide accurate information or omission of facts herein may disqualify me from consideration for employment with THE AFOREMENTIONED COMPANY. Furthermore, if there is a discrepancy with the information provided by myself on this form and that disclosed by a Canadian Police Department during this investigation of my criminal records history, I understand that I have the option to provide my fingerprints to resolve any discrepancy or dispute. This request is made in compliance with any applicable federal, provincial or municipal public sector privacy legislation which allows a public body or municipality to disclose my personal information to me or my agent upon my request. By signing this form, I am aware and I give consent that this record may be transmitted electronically or in hard copy outside of Canada.Candidate’s Signature Authorizing Name Based Criminal CheckDate MM slash DD slash YYYY In connection with my application for employment with THE AFOREMENTIONED COMPANY I understand that background check process includes a Canadian credit bureau inquiry with retrieval of information from a major Canadian credit bureau. I hereby consent to a Canadian credit bureau inquiry on behalf of References and More Services and/or its agents which will include information about me, including any previous bankruptcies, legal proceedings, collection actions, negative banking items and other information reported by my creditors and I hereby authorize any public or private institution to provide and release References and More Services and/or its agents information related to my credit record. I authorize References and More Services and/or its agents to release all personal information obtained during the above Canadian credit bureau inquiry to THE AFOREMENTIONED COMPANY and hold harmless References and More Services and/or its agents upon the release of this information or its findings to References and More Services and/or its agents.Candidate’s Signature Authorizing Credit Bureau InquiryDate MM slash DD slash YYYY Δ