Criminal Check Form - IRISS Corporation

A. Personal Information

Surname (last name)*

Given name(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*

Prov./Terr./State*

Postal/ZIP*

Previous Address(es) Within the Last 5 Years

Number

Street

Apartment

City

Prov./Terr./State

Postal/ZIP

Number

Street

Apartment

City

Prov./Terr./State

Postal/ZIP

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 CPIC Investigative Data Bank.

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 RSSI & LEGALEASE DOCUMENT SERVICE, located in OTTAWA & CALGARY, CANADA.

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 POLICE SERVICE to RSSI & LEGALEASE DOCUMENT SERVICE, OTTAWA & CALGARY, CANADA.

Signature of Applicant*

Date (Year - Month - Day)*

Signed At City*

Signed At Province/Territory*

The information will be stored, in Canada, at RELIABILITY SCREENING SOLUTIONS INC, OTTAWA CANADA.

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

Do you have a criminal record?*

Yes
No

Please attach your ID documents*

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 128 MB, Max. files: 3.

Declaration of Criminal Record

This form is required to be filled out because you have said yes to having a Criminal Record. It must accompany your Informed Consent Form (first section) 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)

Please attach your ID documents*

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 128 MB, Max. files: 3.

CAPTCHA

Online Criminal Record Check

A. Personal Information

B. Reason for the Criminal Record Verification

C. Informed Consent

Declaration of Criminal Record