Police Records Check Form
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1
2POLICE RECORDS CHECK FOR SERVICE
WITH THE VULNERABLE SECTOR
FORM #306/Rev. June 2015
Agency and Position Applying for:
PRINT CLEARLY. THIS WILL BE USED TO MAIL YOUR FORM BACK TO YOU.
< First Name, Middle Name, Surname
NON-VOLUNTEER
VOLUNTEER
< Unit/Number, Street
Verified by:
< City, Province
< Postal Code
Non/Profit Member:
< How long have you lived at
Sex:
M
F
this address?
Maiden Name:
Other Names Used:
Date of Birth (yy/mm/dd):
|
|
Place of Birth:
Home Phone Number:
Business Phone Number:
FIVE YEAR ADDRESS HISTORY IF DIFFERENT THAN ABOVE (*Any address outside Ottawa jurisdiction must include name of Police Service)
Unit/Number:
Street:
City:
Prov.:
Postal Code:
How Long?:
Unit/Number:
Street:
City:
Prov.:
Postal Code:
How Long?:
Unit/Number:
Street:
City:
Prov.:
Postal Code:
How Long?:
Other Police Agency
1.
I consent to a search being made in the automated criminal records retrieval system maintained by the Royal Canadian Mounted Police to find out if I have been charged
and/or convicted of any criminal offences or convicted and granted a pardon for any of the sexual offences that are listed in the schedule of the Criminal Records Act.
I understand that, as a result of giving this consent, if I am suspected of being the person named in a criminal record for one of the sexual offences listed in the schedule
to the Criminal Records Act in respect of which a pardon was granted or issued, that record may be provided by the Commissioner of the Royal Canadian Mounted Police
to the Solicitor General of Canada, who may then disclose all or part of the information contained in that record to a police service or other authorized body. That police
service or authorized body will then disclose that information to me.
2.
I hereby release and discharge the Ottawa Police Service and all their agents from any and all claims, actions and demands for damages, loss or injury of any nature
arising from disclosure of information. I hereby authorize the Ottawa Police Service to inquire into and conduct local police information searches Canada wide and disclose
to myself details of police investigated incidents that the Ottawa Police believes may assist an agency in making an informed decision concerning my application.
Furthermore, I understand that upon the disclosure of information, the Ottawa Police Service and all their agents waive any responsibility for its use and or subsequent
dissemination by myself.
3.
I certify that the information provided by me in this application is true and correct to the best of my knowledge and belief. I have read this consent, understand it and
agree to it in its entirety.
SIGNATURE OF APPLICANT:
Signed this date:
, 201
PAGE 1 OF ___
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