CANADIAN CRIMINAL RECORD VERIFICATION

INFORMED CONSENT FORM GUIDELINES

Business Information Group, Inc. Empowered by Ver t ical Screen® Propr ieta ry & Con f ident ia l

251 Veterans Way, Warminster, PA 18974 help@bigreport.com | bigreport.com

Revised 12/08/2017 P35F3A-0

SECTION A: PERSONAL INFORMATION

All information fields on the Criminal Record Verification Informed Consent Form must be completed. If any information is

left blank, your form may be rejected—to ensure the fastest possible completion of your background screening, be as thorough

as possible while filling out the form.

You must include any maiden, alternate, or alias names, including nicknames and/or spelling variants. First and last

names can be listed separately, so there is no need to provide every possible combination of aliases so long as each

first and last name appears at least once.

Include all addresses where you have lived during the past five years, regardless of country.

Please ensure that you write your date of birth in YYYY-MM-DD format

Additional names and addresses can be included clearly labeled on a blank page with your name and signature

SECTION B: REASON FOR THE CRIMINAL RECORD VERIFICATION

Canadian criminal record checks can only be conducted for specific purposes. Please fill out the Reason for Request and

Organization Requesting Search fields as indicated on the form. The Contact Name and Contact Phone Number in this section

refer to a representative of the organization requesting your background screening (your current or prospective

employer/school)

SECTION C: INFORMED CONSENT

Please read section C thoroughly before signing. Your signature must be done by hand to indicate that you have given

permission for us to conduct your Canadian criminal background screening. Typed signatures will not be accepted.

Do not check off the Police Information Portal (PIP) check box.

Do not check off the OTHER check box.

SECTION D: IDENTIFICATION VERIFICATION

Positive identity verification is required. You must meet face to face with a representative of the organization which

requested your background screening. During this meeting, the representative will confirm your identity against your provided

documents and sign the bottom of the form.

If you are unable to meet in person, you should obtain a certified true copy of your identity documents from a

public notary and leave Section D blank. BIG will use the certified IDs to verify your identity.

CANADIAN CRIMINAL RECORD VERIFICATION

INFORMED CONSENT FORM GUIDELINES

Business Information Group, Inc. Empowered by Ver t ical Screen® Propr ieta ry & Con f ident ia l

251 Veterans Way, Warminster, PA 18974 help@bigreport.com | bigreport.com

Revised 12/08/2017 P35F3A-0

IDENTITY DOCUMENTS

You must provide copies of the two valid identifying documents which were used to verify your identity. If you were unable to

meet in person with a representative of the organization which requested your background screening for identity verification,

the copies must be certified true copies prepared by a notary.

Both must be unexpired and at least one must be a government issued photo ID bearing your signature. When copying your

IDs, please ensure that all relevant information is visible. It may be necessary to copy both the front and back of some IDs in

order to include all identifying information.

Your identity documents may be from any country as long as they are in English or French. Examples of acceptable IDs are given

in the table below—you can provide either two Primary IDs or one Primary and one Secondary ID. Additional document types

or translated documents may be acceptable upon review.

PLEASE NOTE, SIN, SSN AND HEALTH CARDS ARE NOT ACCEPTABLE.

PRIMARY IDS SECONDARY IDS

Driver’s License

Passport

Nexus or Passport Card

Citizenship Card

Permanent Resident Card

Certificate of Indian Status

Firearms Acquisition Certificate (FAC or PAL)

CNIB Identification Card

Federal, Provincial, State or Municipal ID Card

Military or Military Family ID

Government Employment Card

Student ID Card (With Photo)

Age of Majority or LCBO Card

Birth or Baptismal Certificate

Hunting, Fishing or Boating License

Outdoors Card

Hospital Card

Canadian Blood Donor Card

Immigration Papers

If you are unable to meet in person with a representative of the organization requesting your background check, you must have

a certified true copy of your identity documents made by a notary.

DECLARATION OF CRIMINAL RECORD

If you wish to declare a previous conviction, you may do so on the Declaration of Criminal Record form. This additional form is

not required if you do not have a previous conviction you wish to declare.

RETURNING THE FORM

Please return the required documents to BIG by fax at 215-396-2385 using the attached cover page. If you have

any questions, please contact our Client Services Department at 1-800-803-0331 or 00+1+215-876-6143.

CRIMINAL RECORD VERIFICATION Informed Consent Form

A. Personal Information Surname (last name): Given names(s):

Surname (last name) at birth: Former name(s):

Place of birth (City, Province/State, Country):

Date of birth (YYYY-MM-DD): Sex (check one) ☐ Female ☐ Male

Phone number(s): Email address:

Current Home Address

________ _________________________________________________ __________ ___________________ ____________________ ______________

Number Street Apartment City Province/Territory/State Postal/ZIP code

Previous Address(es) Within the Last 5 Years (attach additional page if necessary)

________ _______________________________________________ __________ ___________________ ____________________ ______________

________ _______________________________________________ __________ ___________________ ____________________ ______________

B. Reason for the Criminal Record Verification Reason for Request (example: Employment – Employer – Job Title):

Organization Requesting Search:

Contact Name: Contact Phone Number:

C. Informed Consent

SEARCH AUTHORIZATION – 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.

POLICE INFORMATION SYSTEM(S) – I HEREBY CONSENT TO THE SEARCH OF police information systems, as part of a Police Information Check, which will consist of a search of the following systems (check applicable):

☐ CPIC investigative Data Bank ☐ Police Information Portal (PIP)

☐ OTHER:

AUTHORIZATION AND WAIVER to provide a confirmation of criminal record or any police information.

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 ________________________ , located in________________________________

Company Name City and Country

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 ________________________________ to _____________________________________ , ____________________________. Name of Processing Police Service Company Name City and Country

Signature of Applicant Date

Year – Month - Day

Signed at

City Province/Territory

D. Identification Verification ☐ Physical Identity Verification ☐ Electronic Identity Verification

Witnessing Agent’s Name: Identification Verified:

Witnessing Agent’s Signature: Type of Photo ID Viewed (Government Issued) & Secondary ID

Name and location of the company where information will be stored in Canada:_____________________________________________________________________________.

**Information related to this criminal record check is collected, retained and disclosed in accordance with applicable privacy legislation. **

Date de version du formulaire: 2017-10-05 Cobourg Police Service

_________________________________

_________________________________

CRIMINAL RECORD VERIFICATION Declaration of Criminal Record Form

Declaration of Criminal Record

This form is required to be filled and attached to your Informed Consent Form for a Criminal Record Verification.

Surname (last name) ______________________ Given name(s) ______________________ Date of Birth: __________ YYYY-MM-DD

Information is collected and disclosed in accordance with federal, provincial and municipal laws.

A Declaration of Criminal Record does not constitute a Certified Criminal Record by the RCMP and may not contain all criminal record convictions.

Applicants must declare all convictions for offences under Canadian federal law.

Do not declare the following: - A conviction for which you have received a Record Suspension (formerly pardon) in accordance with the Criminal Records Act; - A conviction where you were a “young person” under the Youth Criminal Justice Act; - An Absolute or Conditional Discharge, pursuant to section 730 of the Criminal Code; - An offence for which you were not convicted; - Any provincial or municipal offence, and; - Any charges dealt with outside of Canada.

Note that a Certified Criminal Record can only be issued based on the submission of fingerprints to the RCMP National Repository of Criminal Records.

Offence Date of Sentence Court Location

_________________________________________________ _________________ Signature of Applicant Date (YYYY-MM-DD)

Verified By:

Name of Police Agency Employee

Signature of Police Agency Employee

Business Information Group, Inc.

251 Veterans Way Warminster PA 18974

P: 800.369.2612 | F: 215.396.9879

bigreport.com

NOTICE OF CONFIDENTIALITY The information contained in this facsimile transmittal is privileged and confidential information intended for the addressee listed above. If you are neither the intended recipient nor the employee or agent responsible for delivering this transmittal to the intended recipient, you are hereby notified that any disclosure, copying, distribution, or the taking of any action in reliance on the contents of the telecopied information is strictly prohibited. If you have received this telecopy in error, please immediately notify us by telephone to arrange the return of the original document to us.

10.16.14

FAX COVER PAGE

DATE: PAGES:

(Including cover page)

URGENT INFORMATION FOR

NAME: Client Services COMPANY: BIG

PHONE: FAX: 215-396-2385

FROM: PHONE: 1-800-803-0331

Business Information Group

COMMENTS:

Canadian Criminal Record Verification Informed Consent Form

Case Reference #