**It is very important that you indicate any name changes, either through marriage, divorce or other legal changes**
Applicant:
LAST/SURNAME
FIRST
MIDDLE
MAIDEN/FORMER SURNAMES OR NAME CHANGES
Address:
STREET / PO BOX / RR # CITY / PROVINCE / STATE
POSTAL CODE / ZIP CODE
Telephone #:
Male
Female
Driver's Lic #
Date of Birth:
Place of Birth : SIN/SSN
YEAR
MONTH
DAY
CITY / PROVINCE /COUNTRY
Education/Professional Accreditation
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Bankruptcy Search
OFAC Search
Social Media Search
Driver’s Abstract
Employment
Verification
Enhanced Reference Check
PPSA Search
Media Search
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Bureau Report
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☐
☐ Education Verification
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☐ Identification Verification
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☐ Security Commissons
Search
☐
☐ Professional Accreditation
Other:
Criminal Record Search - Outside Canada
Version 1.1 (July 2015)-Generic Credit
Company Name
C
ompany
A
ddress
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Applicant Information Section
I authorize the above
named company through its "Agent" to obtain information regarding the items related to me and checked below:
Applicant Signature Section
By signing this waiver, I acknowledge full understanding of it's content and meaning and hereby give my
informed consent.
Applicant's Signature:
Date:
Email Address:
CONSENT TO DISCLOSE PERSONAL INFORMATION
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