Ministry Of Justice Criminal Records Review Program

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SHARING FORM
CRIMINAL RECORDS REVIEW PROGRAM
Application to request to share the results of a previous criminal record check with the Criminal Records Review Program
APPLICANT INFORMATION
LEGAL SURNAME/ LAST NAME
LEGAL GIVEN / FIRST NAME
LEGAL MIDDLE NAME
DATE OF BIRTH:
GENDER:
BIRTHPLACE:
M
F
YYYY
MM
DD
ADDITIONAL NAMES (ALIAS, MAIDEN NAME, ETC.):
Surname / Last name
Given/ First Name
Middle Name
Province:
Residential Address:
Country:
Postal Code:
City:
Country:
City:
Province:
Postal Code:
Mailing Address (If Different from above):
Driver’s Licence #:
Contact phone no.
(
)
ORGANIZATION INFORMATION
Organization that I have already completed a criminal record check for under the Criminal Records Review Program (CRRA):
Organization Name:
Mailing Address:
Country:
Postal Code:
City:
Province:
Office Phone:
(
)
Organization that I request to share the results of my previous criminal record with:
Organization Name:
Mailing Address:
Office Phone:
Country:
Province:
(
)
City:
Postal Code:
Works With (Select ONE default category of Criminal Record Check to be performed for your organization):
Children
or
Vulnerable Adults or
Children and Vulnerable Adults
CONSENT FOR RELEASE OF INFORMATION AND ACKNOWLEDGMENTS:
̆ I understand to share the result of a criminal record check, I must have completed a criminal record check within the last
5 years through the Criminal Records Review Program and the sharing request must be for the same type of check as
previously completed, either for children, vulnerable adults, or both children and vulnerable adults.
̆ I confirm I have completed a criminal record check within the past five years with the Criminal Records Review program
which did not result in a determination of risk to children and/or vulnerable adults as defined in the Criminal Records Review
Act. I understand no details will be disclosed to my organization, only the result. I hereby consent to share the result of the
completed check with the above indicated organization.
̆ I understand that if the registrar determines I do not have criminal record check to share according to the above criteria, I will
be promptly notified.
̆ I understand that within 5 years of the date of this criminal record check verification authorization, should the Criminal
Records Review Program make a determination that I pose a risk to children and/or vulnerable adults, the Deputy Registrar
will promptly provide notification to me and to the persons and entities (organizations) identified in the criminal record check
verification authorization.
Applicant’s signature:
Date signed:
Freedom of Information and Protection of Privacy Act (FOIPPA): The information requested on this form is collected under the authority of the Criminal
Records Review Act section 6.1 and section 26(c) of the Freedom of Information and Protection of Privacy Act (FOIPPA). The information provided will be
used to fulfil the requirements of the Criminal Records Review Act for the release of criminal records information and is in compliance with the FOIPPA. If you
have questions about the collection of your personal information, please contact the Policy Analyst, Criminal Records Review Program, PO Box 9217 Stn
Prov Govt, Victoria, BC V8W 9J1 or by phone at 1-855-587-0185.
Ministry of Justice
Visit the Criminal Records Review Program online at:
Criminal Records Review Program
Policing and Security Programs Branch, Security Programs Division
Email:
sgspdps@gov.bc.ca
PO Box 9217 Stn Prov Govt, Victoria BC V8W 9J1
Phone: toll-free 1-855-587-0185 Fax: (250) 356-1889
CRR022 / 2013-11-21
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