Security Clearance Referral Form
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1
2REGINA POLICE SERVICE
SECURITY CLEARANCE REFERRAL FORM
Page 1 of 2
NAME OF APPLICANT: ___________________________________________________________________________
Surname
Given Name
Middle Name
MAIDEN NAME and/or ANY OTHER NAMES USED: _____________________________________________
ADDRESS: _______________________________________________________________________________________
Apt.#
Street/Avenue
_________________________________________________________________________________________________
City/Town
Province/Postal Code
Telephone Number
SEX: Male / Female
DATE OF BIRTH: ______________________
PLACE OF BIRTH: _________________
Y e a r / M o n t h / D a y
ORGANIZATION/COMPANY/FIRM: _______________________________________________________________
POSITION APPLIED FOR:_____________________________________________
VOLUNTEER: YES / NO
STATEMENT OF CONSENT:
I hereby consent to a Criminal Record Check registered in my name with the Regina Police Service local indices and the National
Repository for Criminal Records in Canada. I further consent, if required, to attend to the Forensic Identification Section of the Regina
Police Service for fingerprint confirmation. I understand that any and all information will be mailed directly to my address as listed above
unless I authorize the waiver below.
Dated this
day of
200_
Signature:
WAIVER for CONSENT of RELEASE OF INFORMATION TO FIRM or ORGANIZATION or COMPANY:
I consent to the release of any and all information pertaining to a Criminal Record registered in my name with the Regina Police Service
local indices and/or with the National Repository for Criminal Records in Canada to the authorized person of the above indicated
Organization/Company/Firm.
I
further
agree
to
absolutely
release,
discharge
and
absolve
the
above
indicated
Organization/Company/Firm and its employees from all claims, losses or damages including indirect or consequential, occasioned by me
during, or as a result of, any investigation for a Criminal Record
.
Dated this
day of
200_
Signature:
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