Criminal Record Verification Informed Consent Form

1. Personal Information

Surname (last name)

Given name(s)

Surname at birth

Former name(s)

Place of birth

Country

Province/State

City

Date of birth

Gender

Male

Female

Unknown

Phone number

Email address

1. Personal Information

5 Year Address History

2. Reason for the Criminal Record Verification

Reason for Request (example: Employment - Employer - Job Title)

Organization Requesting Search

Organization Contact Name

Organization Contact Number

3. Service Required

CPIC investigative Data Bank

Police Information Portal (PIP)

Other

4. I wish to have one or more embossed hard copies mailed to my current address

Identification Document

Upload Photo

Upload Passport Size Photo

Primary Identifications

Secondary Identifications

5. Have you ever been convicted of a criminal offense for which a pardon has not been granted?

Yes

No

Do not declare the following: Absolute discharges or Conditional Discharges, pursuant to the Criminal Code, section 730. Any charges for which you have received a Pardon, pursuant to the Criminal Records Act. Any offences while you were a “young person” (12 years old but less than 18 years old), pursuant to the Youth Criminal Justice Act. Any charges for which you were not convicted, for example, charges that were withdrawn, dismissed, etc. Any provincial or municipal offences. Any charges dealt with outside of Canada.

The system is not able to confirm your criminal record for details. To complete a criminal background check, you will need to visit our office or your local police station along with 2 pieces of identification, one being government issued with photo.

Sorry for the inconvenience

Review

Full Name:
Surname at birth:
Former name:
Date of Birth:
Email:
Telephone:
Place of Birth:
Gender:
Addresses:
Reason for Request:
Organization Requesting Search:
Organization Contact Name:
Organization Contact Number:
Service Required:
Embossed Hard Copy Request:
Identifications Photo:
Primary Identifications:

Secondary Identifications:

Criminal Offences:
Signing Location:

Please review these details carefully. When you click the Next button, online identity verification will begin and you will not be able to return to change your answers.

Authorization and Consent

Please read the following terms and conditions. You may proceed after accepting all terms and conditions.

I have read and accept these terms and conditions

I HEREBY CONSENT TO THE SEARCH OF THE RCMP National Repository of Criminal Records based on the name(s), date of birth and where used, the declared criminal record history provided by myself. I understand that this verification of the National Repository of Criminal Records is not being confirmed by fingerprint comparison which is the only true means by which to confirm if a criminal record exists in the National Repository of Criminal Records. I hereby release and forever discharge all members and employees of the processing Police Service and the Royal Canadian Mounted Police 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 Cobourg/Brockville Police Service to SekCheck Fingerprinting Services Ltd. and/or its agents. 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 the results of the criminal record checks to SekCheck Fingerprinting Services Ltd. and/or its agents.

We require a signature to confirm that you accept all terms and conditions.

Place your cursor in the box shown above, click and drag to create your signature. If you are using a smart phone or tablet, simply use your finger to draw your signature. When done, you will be able to proceed.

Payment

Description	Qty	Rate	Amount
Criminal Record and Judicial Matters Check (CRJMC)	1	$0	$0
Embossed Hard Copy	0	$0	$0
Subtotal			$0
Tax			$0
Total			$0

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