ORANGEVILLE POLICE SERVICE

POLICE CRIMINAL RECORD REQUEST APPLICATION

---

Paid _________________ or Volunteer _______________ Position

Reason for Criminal Record Application: __________________________________
(employment, volunteering, visa, immigration, etc)

Name of Applicant: ______________________________________________________

 

 

Sex: __________________

 

 

Maiden Name or Other Name(s) used:  __________________________________

 

 

Date of Birth ______________  Place of Birth:  __________________________________ 

 

 

Address  ____________________________________________________________________

 

 

Telephone #   __________________________________
    

Previous Addresses for the last 5 years :      __________________________________

 

 

 

____________________________________________________________________________
          

Photo Identification:   _______________________________________________________

 

(must have name and date of birth on I.D. - Drivers Licence #, passport, citizenship, student I.D. cards are acceptable. Do not record S.I.N. or Health Card numbers on this form)

Are you working/volunteering with children or vulnerable persons?    Yes       No

---

 

PLEASE READ CAREFULLY:
I certify that the information set out by me in this application is true and correct to the best of my knowledge and belief. I consent to full disclosure by the Orangeville Police Service to me, the applicant, of the identified police record information. This consent includes the release of records of criminal convictions for which a pardon has not been granted, You Court records that have not non-disclosed, discharges which have not expired in accordance with the Criminal Records Act, or any convictions registered, charges pending or any other judicial order issued under an
Act of Parliament or an Act of the Legislature. This consent also includes and authorizes the release of information available from the files of the Orangeville Police Service or any other police agency, which the Orangeville Police Service deems necessary to fulfill the requirements of this screening process.

I hereby release and forever discharge all members and employees of the Orangeville Police Service 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 Orangeville Police Service.

Applicants must currently reside within the town of Orangeville and make the application in person at 9 Centre Street during business hours. Record Check letters are kept on file for 30 days only. PLEASE pick up the results of your Record Check within this time period. Failure to do so may forfeit the report resulting in re-application/payment for another record check.

Date __________________________________ Signature of Applicant  __________________________________

 

Personal information on this form is collected under the authority of the Police Services Act, S.1 and 41. Questions regarding the collection and use of this form, should be directed to:

 

Records Department

9 Centre Street
Orangeville, Ontario L9W 2W9
(519)941-2522 Ext. 202