Criminal Occurrence Security Check Form - Prince Albert Police Service

PRINCE ALBERT POLICE SERVICE

CRIMINAL OCCURRENCE SECURITY CHECK

NAME OF APPLICANT:

Surname

Given Name

Middle Name

Male

Female

MAIDEN NAME and/or Any other

names used:

CURRENT ADDRESS:

Apt#

Street/Avenue

City/Town

Prov/Postal Code

Previous address (

if residing outside of

Prince Albert in the past 6 Months)

Apt#

Street/Avenue

City/Town

Prov/Postal Code

TELEPHONE NUMBER

Date of

Place of

Birth

Birth

Year – Month - Day

Organization/Company/Firm/School/Course:

Job Description/Reason for Application:

Volunteer

NO

YES

STATEMENT OF CONSENT:

I consent to a search of all records available at the time the search is conducted, including charges before the courts, (including active alternative

measures, stays of proceedings entered within one year of this request and findings of unfit to stand trial) findings of guilt or convictions (including youth

records accessible under section 119(2) of the Youth Criminal Justice Act) and court orders (including peace bonds, restraining orders and

recognizances under sections 810.01, 810.1 or 810.2 of the Criminal Code) registered in my name in the National Repository and local records available

to the police service. I understand that if a possible record exists, it will not be disclosed until identification has been confirmed by either myself or by

fingerprints. I also understand that apprehensions, orders or other records relating to The Mental Health Services Act or The Youth Drug Detoxification

.

and Stabilization Act will not be disclosed

Dated this

day of

201_

Signature:

WAIVER for CONSENT of RELEASE OF INFORMATION TO FIRM or ORGANIZATION or COMPANY:

I consent to the release of any and all information from available records to the authorized person of the above indicated Organization/Company/Firm. I

understand that the disclosure of any possible record will not occur unless identification has been confirmed by either myself or by fingerprints and that

youth records will only be disclosed to persons having access under section 119(1) of the Youth Criminal Justice Act.

Dated this

day of

201_

Signature:

CONSENT FOR PERSONS APPLYING FOR POSITIONS WITHIN THE VULNERABLE SECTOR

If you are an applicant for a paid or volunteer position

i)

with a person or organization responsible for the well-being of one or more children or vulnerable persons, and

ii)

if the position is a position of authority or trust relative to those children or vulnerable persons

please complete the following consent.

Description of the paid or volunteer position:

Provide details regarding the children or vulnerable persons: (e.g.: age, number of persons, nature of vulnerability, etc.)

I consent to a search being made in the automated criminal records retrieval system maintained by the Royal Canadian Mounted Police to determine if I

have been found guilty or convicted of, and/or have been granted a pardon for, any of the sexual offences that are listed in the schedule to the Criminal

Records Act..

I understand that, as a result of giving this consent, if I am suspected of being the person named in a criminal record for one of the sexual offences listed

in the schedule to the Criminal Records Act in respect of which a pardon was granted or issued, that record may be provided by the Commissioner of the

Royal Canadian Mounted Police to the Solicitor General of Canada, who may then disclose all or part of the information contained in that record to a

police service or other authorized body. That police service or authorized body will then disclose that information to me. If I further consent in writing to

disclosure of that information to the person or organization referred to above that requested the verification, that information will be disclosed to that

person or organization by Prince Albert Police Service.

Dated this

day of

201_

Signature:

Identification Produced:

(1)

(2)

DEPARTMENTAL INFORMATION (POLICE USE ONLY)

PERS: Negative

Positive

CNI/CR:

CR Check Results

Negative

Positive

Special Query (

RMS CHECK: Negative

Positive

CNIVS):

Negative

Positive

Member processing application_________________________ DATE: _______________________________

“

When you interact with our staff or use our services, your personal information may be collected by the Prince Albert Police Service under the authority of the Saskatchewan Local Authority of Freedom of

Information and Protection of Privacy Act (LAFOIP) S. 24. If you would like information about the collection of your personal information, please contact the Prince Albert Police Service LAFOIP

Coordinator at (306)953-4338 or accessandprivacy@papolice.ca