AUTHORIZED CONTACT - CONSENT
TO A CRIMINAL RECORD CHECK
Legal Surname / Last name: Legal Given / First Name: Legal Middle Name:
Date of Birth: Sex: M F Birthplace:
YYYY MM DD
Additional Names (Alias, Maiden Name, etc.):
Surname / Last Name: Given / First Name: Middle Name:
Mailing Address
City: Province: Country: Postal Code:
City: Province: Country: Postal Code:
Contact Area Code & Phone No.
Driver's Licence or BCID #:
Applicant Signature
Website:
http://www2.gov.bc.ca/gov/content/safety/crime-prevention/criminal-record-check
Phone: 1-855-587-0185 (Option 2)
CRR015 REV 01/JUNE/2019
Page 1 of 1
Ministry of Public Safety and Solicitor General
Criminal Records Review Program
Policing and Security Programs Branch
Security Programs Division
Residential Address (if different from above):
CRR015
Date Signed YYYY / MM / DD
PART 2: PERMISSION, WAIVER, AND RELEASE
I have read and understand the Permission, Waiver, and Release below. I hereby consent to these terms as indicated
by my signature below:
PERMISSION, WAIVER AND RELEASE: Pursuant to Section 8(1) of the Privacy Act of Canada, and Sections 32(b) and 33.1(1)(b) of the British Columbia
Freedom of Information and Protection of Privacy Act (FOIPPA), by my signature above I hereby consent to a check for records of criminal convictions,
outstanding charges, and/or arrests. Other documents or information in the custody of the police, the courts, corrections, or crown counsel may be accessed in
order to assess any information found as a result of the criminal record check.
I authorize the release of this information to the CRRP of the Ministry of Public Safety and Solicitor General for the purposes of determining my suitability as an
Authorized Contact for an organization covered by the CRRP. This information is collected under the authority of s.26(c) of FOIPPA. Any questions about the
collection and use of this information can be directed to the Policy Analyst, Criminal Records Review Program, PO Box 9217 Stn Prov Govt, Victoria, BC V8W
9J1 or by phone at to 1-855-587-0185.
I hereby release and forever discharge (i) Her Majesty the Queen in Right of Canada, the Royal Canadian Mounted Police, their members, employees, agents
and assigns, and (ii) Her Majesty the Queen in Right of the Province of British Columbia and all employees and agents of the Province of British Columbia from
any and all actions, causes of actions, claims, complaints and demands for any form of relief, damages, loss or injury which may hereafter be sustained by
myself, howsoever arising from the above authorized disclosure of information and waive all rights thereto.
Where the results of a check indicate that a criminal record or outstanding charge may exist, I agree to provide my fingerprints to verify such criminal record.
I understand that providing my Driver’s Licence number or BCID number pursuant to this criminal record check authorization will facilitate identification
requirements; and, in accordance with Sections 32(b) and 33.1(1)(b) of the Freedom of Information and Protection of Privacy Act (FOIPPA), I hereby consent
to the release of my Driver’s Licence number or BCID number, name, date of birth and gender to the Insurance Corporation of British Columbia by the CRRP
for ID verification purposes.
Email address for the proposed Authorized Contact (crc results will be sent to this email address):
This form is to only be completed by a proposed Authorized Contact that will not be working with children and/or
vulnerable adults.
PART 1: AUTHORIZED CONTACT APPLICANT INFORMATION
To be completed by the proposed Authorized Contact:
