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EMPLOYEE/APPLICANT - CONSENT TO A CRIMINAL RECORD CHECK

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Country of origin: CANADA
File type: PDF

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EMPLOYEE/APPLICANT - CONSENT TO A
CRIMINAL RECORD CHECK COVER PAGE
THIS FORM MUST BE SIGNED BY THE EMPLOYER ORGANIZATION AUTHORIZED CONTACT AND
SUBMITTED WITH THE EMPLOYEE/APPLICANT CONSENT FORM
SECTION 1: FOR AUTHORIZED CONTACT USE
SECTION 2: FOR EMPLOYEE/APPLICANT USE
CONSENT TO A CRIMINAL RECORD CHECK - EMPLOYEE/APPLICANT CHECKLIST
I have completed the attached consent form truthfullyclearl\DQG legibly, and signed and dated it.
My organization has verified my I.D. in person to confirm my identity and ensure that the information on the consentform is accurate.
My employer or organization will retain the originals of the forms and will forward a copy to the CRRP on my behalf.
I have read and understand the Consent for Release of Information and Acknowledgements (below) and information regarding the
Freedom of Information and Protection of Privacy Act (FOIPPA) on Page 2.
CONSENT )25 RELEASE OF INFORMATION AND ACKNOWLEDGMENTS
PURSUANT TO THE BC CRIMINAL RECORDS REVIEW ACT:
I hereby consent to a check of criminal charges and convictions to determine whether I have a conviction or outstanding charge for any
relevant or specified offence(s) under the Criminal Records Review Act. 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.
I hereby consent to a check of all available law enforcement systems, including any local police records.
I hereby consent to a Vulnerable Sector search to check if I have been convicted of and received a record suspension (formerly known as a
pardon) for any sexual offences as per WKHCriminal Records Act. For more information on Vulnerable Sector searches, please visit the
RCMP website: http://www.rcmp-grc.gc.ca/en/faqs-about-vulnerable-sector-checks
I understand that as part of the Vulnerable Sector search, I may be required to submit fingerprints to confirm my identity.
I hereby authorize the release to the Deputy Registrar any documents in the custody of the police, the courts, corrections, and crown
counsel relating to any outstanding charges or convictions for any relevant or specified offence(s) as defined under the Criminal
Records Review Act or any police investigations, charges, or convictions deemed relevant by the Deputy Registrar.
Where the results of a check indicate that a criminal record or outstanding charge for a relevant or specified offence(s) may exist, I agree to
provide my fingerprints to verify any such criminal record.
My organization and I will be notified that I have an outstanding charge or conviction for a relevant or specified offence(s), and that the matter
has been referred to the Deputy Registrar for review.
The Deputy Registrar will determine whether or not I present a risk of physical or sexual abuse to children and/or physical, sexual, or
financial abuse to vulnerable adults as applicable; the determination will include consideration of any relevant or specified offence(s) for
which I have received a record suspension (formerly known as a pardon).
If I am charged with or convicted of any relevant or specified offence(s) at any time subsequent to the criminal record check authorization
herein, I further agree to report the charge(s) or conviction(s) to my organization and provide my organization, in a timely manner, with a new
signed Consent to a Criminal Record Check Form.
Website: http://www2.gov.bc.ca/gov/content/safety/crime-prevention/criminal-record-check
Phone: 1-855-587-0185 (Option 2)
CRR010 REV 01/JUN/2019
Page 1 of 2
Ministry of Public Safety and Solicitor General
Criminal Records Review Program
Policing and Security Programs Branch
Security Programs Division
AUTHORIZED CONTACT SIGNATURE REQUIREMENT - ACCOUNTABILITY AND ACKNOWLEDGEMENTS
CONSENT TO A CRIMINAL RECORD CHECK - EMPLOYER ORGANIZATION CHECKLIST
CRR010
The employee/applicant has provided P\RUJDQL]DWLRQ with the original, completed and signed consent form to submit to the Criminal
Records Review Program (CRRP). FORMS SUBMITTED BY APPLICANTS',5(&7/<727+(&553 WILL NOT BE PROCESSED.
0\RUJDQL]DWLRQwill submit a copy of the consent form to the CRRP and will retain the original consent form for 5 years.
0\RUJDQL]DWLRQwill verify the I.D. of each employee/applicant in person to confirm their identity and ensure that the information
provided on the consent form is accurate.
0\RUJDQL]DWLRQKDV reviewed the schedule type and works with category of the form.
AUTHORIZED CONTACT NAME:
SIGNATURE:
I acknowledge the need for proper I.D. verification for the CRRP to conduct a complete risk assessment, and the critical
importance of my organization diligently carrying its duties in this regard. Any false statements or deliberate omissions on
a consent form filed with the CRRP may result in the inability of the CRRP to accurately determine whether the applicant
poses a risk to children or vulnerable adults.
On behalf of the organization, I confirm that the employee's/applicant's primary and secondary I.D. have been verified.
EMPLOYEE/APPLICANT CONSENT TO A
CRIMINAL RECORD CHECK
Page 2 of 2
Ministry of Public Safety and Solicitor General
Criminal Records Review Program
Policing and Security Programs Branch
Security Programs Division
Website: http://www2.gov.bc.ca/gov/content/safety/crime-prevention/criminal-record-check
Phone: 1-855-587-0185 (Option 2)
CRR010 REV 01/JUNE/2019
B C
children
Schedule Type (Choose one):
WORKS WITH (Choose one):
D E
children and vulnerable adults
PART 1: APPLICANT INFORMATION
Legal Surname / Last Name:
Legal Given / First Name: Legal Middle Name:
Date of Birth:
YYYY MM DD
Sex:
M F
Birthplace:
Additional Names (Alias, Maiden Name, etc.):
Surname / Last Name: Given / First Name: Middle Name:
Residential Address (If different from above):
City: Province: Country:
Postal Code:
Mailing Address:
City: Province: Country:
Postal Code:
Contact Phone No.: Driver's Licence or BCID#:
CRR010
PART 2: ORGANIZATION INFORMATION
To be completed by an Authorized Contact of the organization:
Organization Name:
Authorized Contact Name and Title: ID Number (Provided to the organization from the CRRP):
Mailing Address:
City: Province: Country: Postal Code:
Office Area Code & Phone No:
PART 4: SCHEDULE D ONLY MUST PROVIDE
Licensed Child Care Name, Adult Care Facility Name, or Contracted Company Name:
CONSENT FOR RELEASE OF INFORMATION AND ACKNOWLEDGMENTS
Applicant Signature
PART 3: POSITION WITH ORGANIZATION (REQUIRED)
Applicant's Position / Job Title with Organization:
Date Signed YYYY / MM / DD
IMPORTANT: Please read information and instructions on Page 1. To avoid processing delays, ensure all fields
are complete. Providing your Driver's Licence number or BCID number may expedite the process. Your
organization must complete the Schedule Type and 'WORKS WITH' category portion of the form.
vulnerable adults
A
PART 5: CONSENT FO
I have read and understand the Consent for Release of Information and Acknowledgments on Page 1. I hereby consent to these terms as indicated
by my signature below:
R RELEASE OF INFORMATION AND ACKNOWLEDGMENTS
Freedom of Information and Protection of Privacy Act: The information requested on this form is collected under the authority of the Criminal Records Review
Act section 4(1) and section 26(c) of the Freedom of Information and Protection of Privacy Act (FOIPPA). The information provided will be used to fulfil the requirements of
the Criminal Records Review Act for the release of criminal records information in accordance with the FOIPPA. If you have questions about the collection of your personal
information, please contact the Policy Analyst, Criminal Records Review Program, PO Box 9217 Stn Prov Govt, Victoria, BC V8W 9J1 or by phone at 1-855-587-0185 (Option 2).
For Internal Use
Applicant E-mail Address (REQUIRED to receive your payment options):
BC EMERGENCY HEALTH SERVICES
98006
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EMPLOYEEAPPLICANT - CONSENT TO A CRIMINAL RECORD CHECK

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Completed 7 December 2021

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