Consent And Request For Police Information Check For Police Certificate Form - Delta Police Department

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lice Department
Delta Police Use Only
Log:
Delta Police Department
Receipt:
Consent and Request for Police Information Check for
POLICE CERTIFICATE
Instructions: Coplete all questions in Part 1 and Part 2. Refer to Delta Police website (deltapolice.ca) for all requirements for your application
PART 1
APPLICANT
Full Name of Applicant: ____________________________________________________________________________________________
(Same as on photo ID)
Surname
Given 1
Given 2
Given 3
Other Former Surnames and Aliases: ________________________________________________________________________________
Birthdate: Year:________Month:____________Day:_____ Male
or Female
City of Birth: ________________________________
Current Address:_________________________________________________________________________Postal Code:______________
Previous addresses in the last five years (if more space required, use reverse side of form):
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
Phone:
(________) ________-___________
Cell: (________)________-___________
Work: (________)________-___________
Photo ID Provided: _______________________________________________________________________________________________
(Indicate type of ID e.g. Driver's licence number and jurisdiction; provincial ID and number; passport number and country; Canadian citizenship card number)
I have applied for ______________________________________and am required by the ________________________________________
to disclose whether or not I have any convictions or have been charted under any Federal enactment.
PART 2
DISCLAIMER
I hereby authorize the Delta Police Department to conduct a search of my criminal history, including but not limited to any convictions, absolute or conditional discharges or
charges under any enactment for which a disposition is awaiting or has been entered, and local indices checks, and request Delta Police Department to provide such
information to me. In consideration of the foregoing, I hereby release the Delta Police Department, Delta Police Board, The Corporation of Delta, and their respective
elected officials, members, officers, employees and volunteers from any damages I may suffer as a result of my disclosure of this information to any third party. If no
criminal records are found a Police Certificate will be provided. I understand that if a criminal record is found a Police Certificate will not be provided.
Signature of Applicant: ________________________________________________ Date: _____________________________________
*****FOR OFFICE USE ONLY*****
QUERY TYPE
Queried by:
Negative
Attached
Date
CPIC
PRIME
PIP/LEIP
JUSTIN
1406

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