Application For Criminal Record Search Certificate - Winnipeg Police Service

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DATE RECEIVED
WINNIPEG POLICE SERVICE
APPLICATION FOR
CRIMINAL RECORD SEARCH CERTIFICATE
Mail this completed form, with a photocopy of proper identification and fee (see: Information on Requests and Fees), to:
Winnipeg Police Service, P.O. Box 1680, Winnipeg, Manitoba R3C 2Z7 Attention: Bureau of Police Records
SECTION 1 - Identification of the Applicant (
NO INITIALS
When completing this section, please write all names in full –
)
Surname (Last/Family Name)
First Name
Middle Name
Male
Female
Other Names Used: (maiden, birth, etc.)
Date of Birth:
Birth Place:
(YEAR, MONTH, DAY)
(PROVINCE OR COUNTRY)
Address:
City:
Postal Code:
Home Phone Number:
Identification Provided:
Signature:
SECTION 2 - Nature of Position
Job Title / Volunteer Position / Course:
The Name of the Person or Organization is:
Employment / Volunteer - Non Vulnerable
Vulnerable Sector
(employment / volunteer / student / foster parent / adoption / homestay / education / other as stated below)
Visa or Immigration Purposes
U.S. Border Cross / U.S. Employment
Other:
VULNERABLE SECTOR - Persons under 18 years of age or persons who due to their age, disability or other
circumstances, are dependent on others or are at a greater risk of harm than the general population from a person in a
position of authority or trust. If working or volunteering with a vulnerable sector you must sign the consent below.
SECTION 3 - Vulnerable Sector Consent
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 convicted of, and been granted a pardon for, any of the sexual offences that are listed in the schedule to 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 force or other authorized body. That police force or authorized body will then disclose that information to me. If I further consent in writing to
disclosure of that information to the person or organization referred to above that requested the verification, that information will be disclosed to that
person or organization.
Signature
Date
If paying by credit card:
VISA
MASTERCARD
AMERICAN EXPRESS
CREDIT CARD #:
EXPIRY DATE:
SECTION 4 - Office use Only
Receipt No.
Amount $
,
The personal information is being collected for the purpose of conducting a criminal record search and to
provide the applicant with a Criminal Record Search Certificate. The personal information is protected by the
Protection of Privacy provisions of the Freedom of Information and Protection of Privacy Act. Questions about
the collection may be directed to (204)986-6052.
P-612 09 03 17

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