Child Abuse Register
Request for Search (Form A)
www.novascotia.ca/coms CAR-4001 30112016 V.11
We will send confirmation that your name does not appear
on the register to the mailing address you gave above.
You may share this letter with volunteer organizations
and/or employers.
1 Will you have contact with children under age 19?
Yes, complete this form No, do not complete this form. We cannot search the register for your name.
W
e are authorized to search the Nova Scotia Child Abuse Register only if you have contact with children under the age of 19. Search
results are for Nova Scotia only.
2 Give your personal information (please print)
Las
t name: __________________________________________________ First name: _______________________________________
Middle names: _______________________________________________ Last name at birth: _________________________________
All other names during your lifetime: _____________________________________________________________________________
Commonly used names, nicknames, aliases: _________________________________________________________________________
Date of birth (dd/mm/yyyy): _____________________________________ Gender: Male Female Transgender
Health card number: __________________________________________ Drivers license master number: _______________________
Current mailing address: __________________________________________________ Apt/Unit #: ______________________________
City: __________________________________________________________________ Postal Code: ____________________________
Phone: Home (xxx-xxx-xxxx): __________________________________ Cell (xxx-xxx-xxxx): _______________________________
Are you a current or former resident of Nova Scotia? Yes No
3 Attach photocopy to prove your identity
I
nclude proof of your identity. Attach a photocopy of your valid Canadian: Driver’s license, Health card or Passport
If you do not have proof of your identity, please contact us at the number listed at the bottom of this form.
4 Sign the request and certification
P
lease confirm that my name is not entered in the Nova Scotia Child Abuse Register.
I certify that the information given on this form is correct.
Signature: __________________________________________________ Date(dd/mm/yyyy): ____________________________________
5 Send the form to us
Private and Confidential
Child Abuse Register
Department of Community Services
P.O. Box 696
Halifax, Nova Scotia B3J 2T7
Q
uestions? Call 902-424-6798
As of this date, _______________________________________ the name of
the above HAS NOT been entered in the Child Abuse Register.
Consent withdrawn by applicant
Authorized signature: ________________________________________________
Certified by the Department
of Community Services
Child Abuse Register
(stamp)
