POLICE RECORDS CHECK FOR SERVICE WITH THE VULNERABLE SECTOR
FORM #306/Rev. Feb 2009 PRINT CLEARLY. THIS WILL BE USED TO MAIL YOUR FORM BACK TO YOU. < First Name, Middle Name, Surname < Unit/Number, Street < City, Province < Postal Code < How long have you lived here? Veried by: Non/Prot Member: Sex: M F NON-VOLUNTEER VOLUNTEER Agency and Position Applying for:
Maiden Name: Place of Birth:
Other Names Used: Home Phone Number:
Date of Birth (yy/mm/dd): Business Phone Number:
FIVE YEAR ADDRESS HISTORY IF DIFFERENT THAN ABOVE (*Any address outside Ottawa jurisdiction must include name of Police Service) Unit/Number: Unit/Number: Unit/Number: Street: Street: Street: City: City: City: Prov.: Prov.: Prov.: Postal Code: Postal Code: Postal Code: How Long?: How Long?: How Long?:
Other Police Agency*
1. I consent to a search being made in the automated criminal records retrieval system maintained by the Royal Canadian Mounted Police to nd out if I have been charged and/or convicted of any criminal offences or convicted and granted a pardon for any of the sexual offences that are listed in the schedule of 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. I hereby release and discharge the Ottawa Police Service and all their agents from any and all claims, actions and demands for damages, loss or injury of any nature arising from disclosure of information. I hereby authorize the Ottawa Police Service to inquire into and conduct local police information searches Canada wide and disclose to myself details of police investigated incidents that the Ottawa Police believes may assist an agency in making an informed decision concerning my application. Furthermore, I understand that upon the disclosure of information, the Ottawa Police Service and all their agents waive any responsibility for its use and or subsequent dissemination by myself. I certify that the information provided by me in this application is true and correct to the best of my knowledge and belief. I have read this consent, understand it and agree to it in its entirety.
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SIGNATURE OF APPLICANT:
Signed this date:
, 200
VOID without Ottawa Police seal
FOR POLICE USE ONLY
This is to conrm that no criminal convictions, outstanding charges, nor pardoned sex offenses have been found in the Canadian National Repository of Criminal Records as a result of a search based on the above name and date of birth. The search has not been conrmed by ngerprints. This is to notify that there may be criminal convictions, outstanding charges, or pardoned sex offenses associated to the above name and date of birth, the existence of which can only be conrmed by the RCMP based on ngerprints. This is to notify that the above person has been involved in notable police incidents related to the ve (5) year address history provided. SEE ATTACHED DISCLOSURE
Date Completed (yy/mm/dd):
(BY POLICE)
Signed:
POLICE AUTHORIZING SIGNATURE
PAGE 1 OF ___
SCREENING INSTRUCTIONS POLICE RECORDS CHECK
The search includes national and local police databases with cooperating police services. The possible existence of criminal convictions and outstanding charges, as well as incidents of all police contacts for the previous ve years will be considered for release. If an outside agency does not provide the police records checks, a stamp stating, NO RESPONSE FROM POLICE SERVICE IN THIS AREA will appear on page one of this form. It is the responsibility of the applicant to contact the outside police agency to obtain a police records check. This search is intended for individuals seeking employment and/or a volunteer position with children or vulnerable person(s). Information is collected and disclosed according to section 29(1) and 32 of the Municipal Freedom of Information and Protection of Privacy Act (MFIPPA) and the Police Services Act, RSO 1990,c.P.15
INFORMATION FOR RELEASE
The following information contained in local police databases may be considered for release when it is deemed appropriate:
This search does not cover the following areas: summary convictions, discharges and pardons (with the exception of sexual offences listed in the schedule to the Criminal Records Act). The information contained on this certicate is accurate on the date issued. For more information, please visit our Web site at ottawapolice.ca
PROCEDURE
1. 2. The Police Records Check Form must not be altered. The applicant must produce two pieces of valid (i.e. not expired) identication that conrm his/her name, date of birth and address. One piece of identication presented must include a photo. Ontario Health Cards cannot be accepted for identication purposes (Health Cards and Numbers Control Act, 1991 section 2.2(1)). The following is a list of items that could be considered acceptable forms of identication. Photo Identication: which provides photo and both name and date of birth of an individual: *Drivers Licence Government Employment Card Military Employment Card Age of Majority Card Canadian Citizenship Card (up-to-date) Indian Status Card International Student Card Passport Permanent Resident Card Possession and Acquisition Licence (PAL) Canadian National Institute for Blind (CNIB) *Recent Utility Bill required to verify current Ottawa address if no Drivers Licence is available. 3. In the case of a possible match, individuals who require a copy of their criminal record, will have to be ngerprinted by the Ottawa Police Service by appointment only. Please contact 613-236-1222 ext. 5485 for an appointment. The fee of $20 for this service is waived for volunteers. Fingerprints will be forwarded by the OPS to the RCMP along with the applicants certied cheque or money order in the amount of $25 (payable to the Receiver General of Canada). Results of the RCMPs search will be mailed directly to the applicant. The RCMP fee is not required if the applicant provides written conrmation of volunteer work from a bona de registered non-prot organization. Police Records Checks are processed in approximately 3-6 weeks, (exception: 6-8 weeks during peak periods) assuming timely response from other police services and depending on request volumes. The $14 service fee can be waived if the applicant presents a letter from a local organization that intends to engage them in a volunteer capacity. The letter must be provided on ofcial letterhead, in original, it must include the name of the person requesting a Police Records Check and must be signed by the manager in charge of volunteer resources. A $33 non-resident surcharge applies to applicants residing outside OPS jurisdiction. A $33 express surcharge applies if service is to be performed on a while you wait basis (only possible if the applicant resided in Ottawa for the past ve years). Non-Photo Identication: which provides both the name and date of birth of an individual: Birth Certicate Baptismal Certicate Hunting Licence Fishing Licence Outdoors Card Hospital Card Immigration Papers
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For more information, please visit our Web site at ottawapolice.ca
