References and More – Criminal Background Form | References and More Services Ltd

Important – to be completed by employer or recruiter

1.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

Identification Verification of Employee

Client Code/Name/Location (Optional)

Witness Email

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

Witness First Name Last Name

Witness Signature

Have 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 Any charges for which you were not convicted, for example, charges that were withdrawn, dismissed, etc.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)

Date

MM

DD

YYYY

Gender

Male
Female

Present Address

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

Telephone

Previous Address (if present address is less than 5 years)

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

Date