Appendix E Police Information Check - Gananoque Police Service
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2Appendix E
Gananoque Police Service - POLICE INFORMATION CHECK
POLICE VULNERABLE SECTOR CHECK
(Unit 3 must also be completed)
Date of Request
UNIT 1. TO BE COMPLETED BY APPLICANT
_____/_____/_____
Mailing Address (name, street, city, province, postal code)
yy
mm
dd
Must Print Legibly Under Each Heading– this is your mailing label
Last Name
First Name
Middle Name
# and Street Name
Apt/Unit #
Maiden Name or other Surnames used
Other First Names
City
Province
Postal Code
Date of Birth
Place of Birth
Gender
____/_____/_____
yy
mm
dd
Address History – please fill out if resident address differs from mailing address and/or if resided OUTSIDE of the Region in the past 5 years.
Street name and # (please state below)
Apt/Unit #
City
Province
Postal Code
# of yrs
Reason for Request (state below
Self-Declaration (if applicable)
)
Reason: (volunteer, employment, or other – if other, please specify)
□
Declaration of Criminal Record Attached
Is “Reason for Request” dealing with the Vulnerable Sector Yes ___ No ___
*** If yes, UNIT 3 must be completed ***
UNIT 2. POLICE USE ONLY - One Box Must be Checked for Each Section
1. RESULTS FOR NAME-BASED CRIMINAL RECORD VERIFICATION
Based solely on the name(s) and date of birth provided and the criminal record information declared by the applicant, a
search of the RCMP National Repository of Criminal Records did NOT identify any records with the name(s) and date of birth of
□
NEGATIVE
the applicant. Positive identification that a criminal record does or does not exist at the RCMP National Repository of
Criminal Records can only be confirmed by FINGERPRINT comparison. Delays do exist between a conviction being rendered
in court, and the details being accessible on the RCMP National Repository of Criminal Records. Not all offences are reported to the
RCMP National Repository of Criminal Records.
Based solely on the name(s) and date of birth provided and the criminal record information declared by the applicant, a
search of the RCMP National Repository of Criminal Records could NOT be completed. Positive identification that a criminal
□
INCOMPLETE
record does or does not exist requires the applicant to SUBMIT FINGERPRINTS to the RCMP National Repository of
Criminal Records by an authorized police service or accredited private fingerprinting company. Delays do exist between a
conviction being rendered in court, and the details being accessible on the RCMP National Repository of Criminal Records. Not all
offences are reported to the RCMP National Repository of Criminal Records.
Based solely on the name(s) and date of birth provided and the criminal record information declared by the applicant, a
search of the RCMP National Repository of Criminal Records has resulted in a POSSIBLE match to a registered criminal
□
POSSIBLE
record. Positive identification that a criminal record does or does not exist at the RCMP National Repository of Criminal
MATCH
Records can only be confirmed by FINGERPRINT comparison. As such, the criminal record information declared by the
applicant does NOT constitute a Certified Criminal Record by the RCMP. Delays do exist between a conviction being rendered
(See attached page
in court, and the details being accessible on the RCMP National Repository of Criminal Records. Not all offences are reported to the
For details)
RCMP National Repository of Criminal Records.
2
RESULTS OF FINGERPRINT COMPARISON SEARCH WITH THE NATIONAL REPOSITORY OF CRIMINAL RECORDS
.
□
NO RECORDS IDENTIFIED - See Attached
□
RECORDS IDENTIFIED – See Attached
□
NOT APPLICABLE
3.
RESULTS OF INVESTIGATIVE DATABANK AND LOCAL INDICES RESULTS
□
NEGATIVE – No information was revealed that can be disclosed in accordance with federal laws and RCMP policies
□
POSITIVE – See attached page(s) for details.
4.
RESULTS OF POLICE VULNERABLE SECTOR SCREENING ONLY
□
A search of pardoned sex offenders was conducted. No information to release.
□
A search of pardoned sex offenders was conducted. Information authorized for release.
□
A search of pardoned sex offenders was not conducted.
Date of Search
Clerk #
►NOT VALID UNLESS EMBOSSED WITH POLICE SEAL
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