Child Abuse Register Request For Search (Form A)
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1Child Abuse Register
Request for Search (Form A)
Community Services
1 Will you have contact with children under age 16?
Yes, complete this form
No, do not complete this form. We cannot search the register for your name.
We are authorized to search the Nova Scotia Child Abuse Register only if you have contact with children under the age of 16. Search
results are for Nova Scotia only.
2 Give your personal information
(please print)
Last name: __________________________________________________ First name: _______________________________________
Middle names: _______________________________________________ Last name at birth: _________________________________
All other last names during your lifetime: _____________________________________________________________________________
Commonly used names, nicknames, aliases: _________________________________________________________________________
Date of birth (dd/mm/yyyy): _____________________________________ Gender:
Male
Female
Transgender
Health card number: __________________________________________ Drivers license master number: _______________________
Current mailing address: __________________________________________________ Apt/Unit #: ______________________________
City: __________________________________________________________________ Postal Code: ____________________________
Phone: Home
(xxx-xxx-xxxx):
__________________________________ Cell
(xxx-xxx-xxxx):
_______________________________
Are you a current or former resident of Nova Scotia?
Yes
No
3 Attach photocopy to prove your identity
Include proof of your identity. Attach a photocopy of your valid Canadian:
Driver’s license,
Health card or
Passport
If you do not have proof of your identity, please contact us at the number listed at the bottom of this form.
4 Sign the request and certification
Please confirm that my name is not entered in the Nova Scotia Child Abuse Register.
I certify that the information given on this form is correct.
Signature: __________________________________________________ Date: ____________________________________________
For staff use only
5 Send the form to us
As of this date, _______________________________________ the name of
Private and Confidential
the above HAS NOT been entered in the Child Abuse Register.
Child Abuse Register
Department of Community Services
Consent withdrawn by applicant
P.O. Box 696
Halifax, Nova Scotia B3J 2T7
Authorized signature: ________________________________________________
We will send confirmation that your name does not appear
on the register to the mailing address you gave above.
You may share this letter with volunteer organizations
Certified by the Department
of Community Services
and/or employers.
Child Abuse Register
Questions? Call 902-424-6798
(stamp)
CAR-4001 05082015 V.09
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