Criminal Record Verification

A. Personal Information

*

Surname (last name): Given names(s):

Surname (last name) at birth: Former name(s):

Place of birth (City, Province/State, Country):*

City State / Province / Region Country

Date of birth*

Sex (check one)

Male
Female

Phone number(s):*

Phone number(s):

Email address:

Current Home Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Previous Address(es) Within the Last 5 Years (attach additional page if necessary)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Previous Address(es) Within the Last 5 Years (attach additional page if necessary)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

B.Reason for the Criminal Record Verification

Reason for Request (example: Employment – Employer – Job Title):

Organization Requesting Search*

Contact Name

First Last

Contact Phone Number

C. Informed Consent

SEARCH AUTHORIZATION – I HEREBY CONSENT TO THE SEARCH OF the RCMP National Repository of Criminal Records based on the name(s), date of birth and where used, the declared criminal record history provided by myself. I understand that this verification of the National Repository of Criminal Records is not being confirmed by fingerprint comparison which is the only true means by which to confirm if a criminal record exists in the National Repository of Criminal Records.

POLICE INFORMATION SYSTEM(S) – I HEREBY CONSENT TO THE SEARCH OF police information systems, as part of a Police Information Check, which will consist of a search of the following systems (check applicable):*

CPIC investigative Data Bank

AUTHORIZATION AND WAIVER to provide a confirmation of criminal record or any police information.

I certify that the information set out by me in this application is true and correct to the best of my ability. I consent to the release of the results of the criminal record checks to*

located in*

(City and Country)

I hereby release and forever discharge all members and employees of the processing Police Service and the Royal Canadian Mounted Police from any and all actions, claims and demands for damages, loss or injury howsoever arising which may hereafter be sustained by myself as a result of the disclosure of information by the

Name of Processing Police Service*

Company Name*

City and Country*

Signature of Applicant*

Date*

Signed at*

City Country

D. Identification Verification

Physical Identity Verification
Electronic Identity Verification

Witnessing Agent’s Name:

First Last

Identification Verified:

Yes
No

Witnessing Agent’s Signature:

Type of Photo ID Viewed (Government Issued) & Secondary ID

Name and location of the company where information will be stored in Canada:

Declaration of Criminal Record

Surname (last name) Given name(s)

Information is collected and disclosed in accordance with federal, provincial and municipal laws. A Declaration of Criminal Record does not constitute a Certified Criminal Record by the RCMP and may not contain all criminal record convictions. Applicants must declare all convictions for offences under Canadian federal law. Do not declare the following: - A conviction for which you have received a Record Suspension (formerly pardon) in accordance with the Criminal Records Act; - A conviction where you were a “young person” under the Youth Criminal Justice Act; - An Absolute or Conditional Discharge, pursuant to section 730 of the Criminal Code; - An offence for which you were not convicted; - Any provincial or municipal offence, and; - Any charges dealt with outside of Canada. Note that a Certified Criminal Record can only be issued based on the submission of fingerprints to the RCMP National Repository of Criminal Records.

Date of Birth:

Offence

Date of Sentence

Court Location

Offence

Date of Sentence

Court Location

Offence

Date of Sentence

Court Location

Offence

Date of Sentence

Court Location

Offence

Date of Sentence

Court Location

Offence

Date of Sentence

Court Location

Offence

Date of Sentence

Court Location

Offence

Date of Sentence

Court Location

Signature of Applicant*

Date*