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  • 6 check-boxes
  • 84 other fields

Country of origin: CANADA
File type: PDF

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CSI Background Screening Email Directory:
General Inquiries: admin@csiscreening.com
Directors: fdehmel@csiscreening.com; tdehmel@csiscreening.com
Corporate Head Office
115 Chain Lake Drive, Unit 2
Halifax, NS B3S 1B3
Tel: 902-450-0697
Fax: 902-484-5379
Toll Free: 888-818-5251
https://csiscreening.com/
In this package you will find all the necessary forms required
to complete this background screening. It is very important
that you complete all the fields and information requested to
avoid any delay in completing the background screening.
Should you require any assistance or if you have any
questions concerning this process, please do not hesitate to
contact one of our friendly professionals for help. We can be
contacted at 888-818-5251, 902-450-0697 or at
csi@csiscreening.com.
PLEASE READ PRIOR TO COMPLETING CONSENTS
Instructions for completion of Consent to Disclosure of Personal Information form,
Declaration of Criminal Record Information and PIC Supplementary Form
These forms are the only forms that the RCMP and CPIC will allow to be used for
conducting name based criminal record checks. Further the RCMP or CPIC will not allow
any changes or additions to these forms.
1. SURNAME - Current legal last name, as shown on legal documents.
2. FIRST NAME - Current legal formal first name as shown on legal documents.
3. MIDDLE NAME - This is your second/middle name and/or names.
4. MAIDEN NAME or OTHER SURNAMES - Please include previous surnames, whether they
are maiden or any other legal previous surnames.
5. PLACE OF BIRTH - Full place name, including province/state and country of birth
6. DATE OF BIRTH - Full and complete date of birth in format shown on form
7. SEX - Current legal gender identification
8. PHONE # - Current contact telephone number
9. CURRENT ADDRESS - It is critical that you enter the full current residential street address
10. PREVIOUS ADDRESSES - This section is again for the applicant to complete their
complete residential previous addresses for the last 5 years.
11. REASON FOR CONSENT - This section is for the applicant to indicate the reason for the
criminal check. If it is for a volunteer position, please indicate the description of the
position.
12. EVER BEEN CONVICTED OF A CRIMINAL OFFENCE IN CANADA - You must indicate if you
have ever been convicted of a criminal offence in Canada in this section. If you indicate
YES, then you MUST complete the attached Declaration of Criminal Offence form.
13. SEARCH AUTHORIZATION - In this section the applicant must select whether or not
the criminal check is a regular name based criminal check (CPIC) and/or to included an
Enhanced Police Check. If you are unsure, please check with your potential employer or
person requesting this check. It is also very important that if the results of this criminal
record check is been transmitted outside Canada, that the Country it is being transmitted to
is included in the space provided.
In the box to the right of this, you MUST read both paragraphs, then date and sign as
having read, understood and consent in the space provided.
14. COMPANY OR ORGANIZATION REQUESTING SEARCH - In the first block please enter
the name of the company requesting the search. In the space marked 1. to the right,
please enter the first photo ID that the witness reviewed to verify the identity of the
applicant. In the space marked 2. enter the second photo ID that the witness used to verify
the applicant's identity. A copy of the IDs MUST accompany the consent form to CSI.
The witness MUST sign in the space provided for their signature indicating that they have
verified the identity of the applicant, by reviewing the two pieces of ID by comparing to the
applicant. The witness will then print their name below their signature.
CONSENT TO DISCLOSURE OR PERSONAL INFORMATION - DECLARATION OF CRIMINAL
RECORD INFORMATION
1. PRINTED NAME OF APPLICANT - Please print your full legal name in this space
2. SIGNATURE OF APPLICANT - Please sign as giving your consent to confirm the
information contained on form.
3. DATE SIGNED - Please insert date signed
4. CONVICTION DATE - It is important that you provide the proper date of each
convicted offence to ensure that proper confirmation can be made.
5. OFFENCE - Please provide the details of the offence committed and police service
6. LOCATION OF OFFENCE - Please enter the place name of the offence
7. It is important to read the information at the bottom of the form so that you
understand the purpose of the consent.
POLICE INFORMATION CHECK _ SUPPLEMENTARY INFORMATION
DATE OF REQUEST - Please enter date of request
LAST NAME - Please enter legal last name
FIRST NAME - Please enter legal first name
MIDDLE NAME - Please enter legal middle name
# AND STREET NAME - Please enter complete residential address
APT/UNIT # - Enter apartment or unit number
MAIDEN NAME OR OTHER SURNAMES - Enter any previous last name
OTHER FIRST NAMES - Enter any previous first names or nicknames
CITY - Please enter current residential city
PROVINCE - Please enter current residential province
POSTAL CODE - Please enter current postal code
DATE OF BIRTH - Enter correct date of birth
PLACE OF BIRTH - Enter correct place of birth
GENDER - Enter legal gender identity
OFFENCE DATE - Enter correct offence date
LOCATION - enter correct offence location
CHARGE - Enter correct charge
DISPOSITION - Please enter as much information as you know about the charge disposition
(Please Print) (To be completed by applicant )
Surname (Last Name) (Provide previous name(s) prior to application if applicable)
First Name Middle Name
Maiden Name or Other Surnames Used (if applicable):
Place of Birth (Province and Country)
Date of Birth
(YEAR-MONTH-DAY)
Sex
Current Address
Number Street Apt/Unit City/Province/Country Postal Code
Provide previous addresses, if any, within the last five (5) years
Number Street Apt/Unit City/Province/Country Postal Code
Number Street Apt/Unit City/Province/Country Postal Code
SEARCH AUTHORIZATION:
Signed this day of
, 20
(Signature of Applicant)
Note: The presence of information does not necessarily mean the applicant will be
disqualified from the position by the organization.
CONSENT TO DISCLOSURE OF PERSONAL INFORMATION
I HEREBY CONSENT TO THE SEARCH OF THE RCMP NATIONAL REPOSITORY
OF CRIMINAL
RECORDS BASED ON THE NAME(S), DATE OF BIRTH AND
DECLARED CRIMINAL RECORD PROVIDED. I UNDERSTAND THAT THE
RESULTS MAY BE TRANSMITTED OUTSIDE CANADA TO (insert country)
_
__
__
________________________________________ IF REQUIRED
A. Criminal Record (Adult)
RELEASE AUTHORIZATION AND WAIVER
I certify that the information set out by me in this application is true and correct to the best
of my ability. I consent to the release of a Criminal Record to CSI Inc. and its partners.
I hereby release and forever discharge all members and employees of the processing Police
Service from any and all actions, claims and demands for damages, loss or injury howsoever
arising which may hereafter be sustained by myself as a result of the disclosure of
information by the processing Police Service to CSI Inc. and its partners.
Note: Information related to this criminal record is collected, retained, and disclosed in accordance with applicable federal,
provincial and municipal privacy legislation
________________________________________________ 2.
Signature of Individual
Witnessing Applicant’s ID
Type of Photo ID Viewed (Government Issued) and Secondary ID Viewed
________________________________________________
Printed Name of Individual Witnessing Applicant’s ID
COMPANY OR ORGANIZATION REQUESTING SEARCH
1.
The Police Criminal Records Check will include the following information as
it exists on the date of the search: The results of a search of the RCMP
National Repository of Criminal Records conducted based on the name(s),
date of birth, and declared criminal record history provided by the
Applicant for Criminal Convictions. The results of a search for Criminal
Records and Summary convictions from the processing Police Service's local
database.
Our Enhanced Police Check (Police Information Check) will include all of
the above and the following information as it exists on the date of the
search: The results of a search of the Investigative Databank of the
Canadian Police Information Centre (CPIC) for outstanding entries such as
charges and warrants, judicial orders, Peace Bonds, Probation and
Prohibition Orders. The results of a search for Absolute and Conditional
Discharges from the processing Police Service's local database.
CPIC:
Enhanced Police Check
(Police Information Check):
Reason for the Consent
Employment Other/Volunteer (If other or volunteer provide description of position)_________________
HAVE YOU EVER BEEN CONVICTED OF A CRIMINAL OFFENCE IN CANADA? YES NO
IF YOU ANSWERED YES TO THE ABOVE STATEMENT, YOU MUST COMPLETE THE DECLARATION OF CRIMINAL RECORD FORM AND ATTACH.
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CONSENT TO DISCLOSURE OF PERSONAL INFORMATION
DECLARATION OF CRIMINAL RECORD INFORMATION
APPLICANT MUST DECLARE ALL CONVICTIONS FOR OFFENCES UNDER FEDERAL LAW
(and POLICE SERVICE if known)
LOCATION OF OFFENCE
DO NOT LIST ANY OF THE FOLLOWING OFFENCES ON THIS FORM:
A conviction for which the Applicant has received a Pardon in accordance with the Criminal Records Act
A conviction where the applicant was a “young person” under the Youth Criminal Justice Act
An Absolute Discharge or Conditional Discharge pursuant to section 730 of the Criminal Code
An offence for which the applicant was not convicted
Any provincial or municipal offence
Any charges dealt with outside of Canada
Declaration of Criminal Record does not constitute a Certified Criminal Record by the RCMP
Declaration of Criminal Record may not contain all criminal record convictions
A Certified Criminal Record can only be issued by CCRTIS based on the submission of fingerprints to the RCMP National Repository of
Criminal Record.
_________________________________________ _________________________________________
Printed Name of Applicant Signature of Applicant
__________________________________________
Date Signed – Year/Month/Day
CONVICTION DATE OFFENCE
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signature
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CSI BACKGROUND SCREENING
Police Information Check
Supplementary Information
APPLICANTS IN
FOR
MATION - Mailing Address
(name, street, city, province, postal
Date of
Request
/ /
yy mm
dd
Last Name
First Name
Middle Name
# and Street Name Apt/Unit #
Maiden Name or other Surnames used
Other First Names
City Province Postal Code
Date of Birth
yy mm dd
Place of Birth
Gender
OFFENCES
Offence Date
Location
Charge
Disposition
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Completed 15 March 2021

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