eConsent Form

Company Name

Company Address

Receipt/Client Account #

B. Applicant Information Section

I HEREBY CONSENT TO THE SEARCH OF THE RCMP NATIONAL REPOSITORY OF CRIMINAL RECORDS BASED ON THE NAME(S), DATE OF BIRTH AND DECLARED CRIMINAL RECORD PROVIDED. I UNDERSTAND THAT THE RESULTS MAY BE TRANSMITTED OUTSIDE CANADA TO MY EMPLOYER FOR EMPLOYMENT PURPOSES. A. Criminal Record (Adult) AUTHORIZATION AND WAIVER Authorization to Release Clearance Report. I certify that the information set out by me in this application is true and correct to the best of my ability. I consent to the release of a Criminal Record to CSI Inc. and its partners. I hereby release and forever discharge all members and employees of the processing Police Service from any and all actions, claims and demands for damages, loss or injury howsoever arising which may hereafter be sustained by myself as a result of the disclosure of information by the processing Police Service to CSI Inc. and its partners. Information related to this criminal record is collected, retained, and disclosed in accordance with applicable federal, provincial, and municipal privacy legislation. Note: The presence of information does not necessarily mean the applicant will be disqualified from the position by the organization.

I understand, authorize and consent that by using this Electronic Identity Verification (EIV/eConsent) process, my identity will be positively verified electronically and once verified, I consent to the above search. I also understand that by providing the secure personal information used in this process that the positive verification of my identity will also be used as my legal informed consent.

Last / Surname

First Name

Middle Name

Maiden Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Gender*

Male
Female

Name Change (if applicable)

Date of Birth*

Place of Birth*

SIN / SSN

C. Self Declaration Section (Required)

Have you ever been convicted of a criminal offence in Canada?*

Yes
No

(If yes provide all Canadian criminal convictions on the Form B pop-out below. These will be verified)

FORM B - Declaration of Criminal Record

Date of Sentence

Place of offense

Charge

Date of Sentence, Charge #2

Place of offense 2

Charge 2

Date of Sentence, Charge #3

Place of offense 3

Charge 3

Date of Sentence, Charge #4

Place of offense 4

Charge 4

Date of Sentence, Charge #5

Place of offense 5

Charge 5

Date of Sentence, Charge #6

Place of offense 6

Charge 6

D. Enhanced (Police Information Portal or PIP) Criminal Record Check.

Police Information Check (PIC), also referred to as the "Enhanced", Self Declaration (if requested by Employer)

Do you have any outstanding warrants, charges, judicial orders, peace bonds, probation/prohibition orders, or any absolute or conditional discharges?

Yes
No

The answer to this, and any other questions in Section D, are only applicable if your order includes the Enhanced (Police Information Portal or PIP) Criminal Record Check.

Declaration of Police Charges

This section is part of the Enhanced (Police Information Portal or PIP) Criminal Record Check., and is only required if the service is ordered.

This search is required by your employer and a description of the search is noted below

Level 2: Police Information Check (PIC)

It is a collection of offence information, including convictions, outstanding warrants, charges and judicial orders available from a local police agency’s records management system and other systems/records where authorized.

This check is intended for applicants who are seeking volunteer and/or employment with agencies who require a criminal record check. The agency has determined that a search of sex offenders with a record suspension is NOT required (e.g., border crossing or visa) therefore this check is NOT intended for applicants who are seeking volunteer and/or employment with vulnerable persons.

The Police Information Check will include the following information;

(a) Criminal convictions from CPIC and/or local databases.
(b) Summary convictions, for five years, when identified.
(c) Findings of Guilt under the Youth Criminal Justice Act within the applicable disclosure period.
(d) Outstanding entries, such as charges and warrants, judicial orders, Peace Bonds, Probation and Prohibition Orders. As per CPIC policy, information obtained from the Investigative Databank must be confirmed and authorized for release by the contributing agency.
(d) Absolute and conditional discharges for 1 or 3 years respectively.

The Police Information Check WILL NOT include:

(a) Convictions where a record suspension has been granted.
(b) Convictions under provincial statutes.
(c) Local police contact.
(d) Ministry of Transportation information (PARIS).
(e) Special Interest Police (SIP) category of CPIC.
(f) Family Court restraining orders.
(g) Foreign information.
(h) A Vulnerable Sector (VS) Query to ascertain if the applicant has been convicted of and granted a record suspension for any of the sexual offences that are listed in the schedule to the Criminal Records Act (CRA).
(i) Any reference to incidents involving mental health contact.
(j) Diversions will not be released as police contact and no reference to the occurrence is permitted (CC S. 717.4).
(k) Youth Criminal Justice Act (YCJA) information beyond applicable disclosure period.
(l) Any reference to contagious diseases.
(m) Dispositions including, but not limited to, Withdrawn, Dismissed, and cases of Not Criminally Responsible by Reason of Mental Disorder.

Date of Offence

Place of Offence

Charges

Disposition

Date of Offence 2

Place of Offence 2

Charges 2

Disposition 2

Date of Offence 3

Place of Offence 3

Charges 3

Disposition 3

Date of Offence 4

Place of Offence 4

Charges 4

Disposition 4

Date of Offence 5

Place of Offence 5

Charges 5

Disposition 5

Date of Offence 6

Place of Offence 6

Charges 6

Disposition 6

Date of Offence 7

Place of Offence 7

Charges 7

Disposition 7

Date of Offence 8

Place of Offence 8

Charges 8

Disposition 8

Date of Offence 9

Place of Offence 9

Charges 9

Disposition 9

Date of Offence 10

Place of Offence 10

Charges 10

Disposition 10

E. Application Email Section

Email*

Date

I hereby declare that the information provided on this form is true and correct to the best of knowledge and belief. I acknowledge that this is not a Certified Criminal Record.

Does your employer require any additional checks?

Yes
No

Form C - Special Order Section

Applicant Information

I authorize the above named company through it's "Agent" to obtain information regarding the items related to me and checked below:

Employer Requirement for "Other"

If your employer requires an additional check that is not listed above, please indicate what requirement is needed.

Authorization*

Yes

By selecting "YES" above, I am indicating that I understand, authorize, and consent that I will have the checks indicated below performed:

A: eConsent Criminal Records Check
B: Global Terrorist Watch Search
C: Education Verification
D: Credit Check (Optional)

Hidden

Coupon

This is temporary for testing purposes, it will be hidden.

Hidden

Order Number

again, this will be a hidden field in the future.

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Consent to Disclose and Release Personal Information