0148E (2014/04) © Queen's Printer for Ontario, 2014 Disponible en français
Ministry of Community Safety
and Correctional Services
Private Security and Investigative
Services Branch
Consent and Release of Liability
Form Regarding Training
Please print or type in black ink
(This space reserved for office use only)
Student Information
Important: You must provide your full legal name, as it appears on the identification you are carrying with you to the test venue on the
test day.
Last Name
First Name
Middle Name(s)
Other Name(s) (Maiden name, former name, etc. - please specify)
Address
Unit No.
Street No.
Street Name
PO Box
City/Town
Province
Postal Code
Business Telephone No.
Ext.
Fax No.
Email Address
Mailing Address (Only complete if different from the address noted above)
Unit No.
Street No.
Street Name
PO Box
City/Town
Province
Postal Code
Date of Birth (yyyy/mm/dd)
Gender
Male Female
I,
consent to and authorize
Student Name
Name of Training Entity
to collect personal information from or about me for the purpose of providing training in accordance with the Training and Testing Regulation
made under the Private Security and Investigative Services Act, 2005 (“PSISA”);
to disclose personal information collected from or about me, including whether or not I have successfully completed the required training
under the Training and Testing Regulation, to the Private Security and Investigative Services Branch of the Ministry of Community Safety
and Correctional Services for the purpose of determining whether I am eligible to be licensed as a security guard or private investigator, and
for the purpose of administering the licensing system authorized under the PSISA; and
I also consent to and authorize the Private Security and Investigative Services Branch of the Ministry of Community Safety and Correctional
Services to disclose personal information collected about me, for the purpose of advising the Ministry’s Test Delivery Vendor as to whether or
not I have completed the training required under the Training and Testing Regulation; and
I hereby release and discharge Her Majesty the Queen in Right of Ontario, the
Name of Training Entity
and their respective directors, employees, subcontractors, volunteers, servants and agents, including their successors and assigns, from any
and all actions, claims and demands for damages, loss or injury, howsoever arising, except as a result of negligence or wilful misconduct which
may hereafter be sustained by myself as a result of the collection, use and disclosure of personal information as authorized by this form.
This Release of Liability shall be binding upon and shall ensure to the benefit of my respective heirs, and administrators.
I certify that I have read the information in this form thoroughly,
that I fully understand it, and that by signing below, I have the capacity to
provide consent, and
that I am providing consent freely and voluntarily.
The information provided is collected under the authority of Section 11 of the Private Security and Investigative Services Act, 2005 for the
purpose of issuing a licence under the Act. If you have any questions, call a ServiceOntario Customer Service Representative toll-free at 1-866-
767-7454 (Canada). TTY users call us toll-free at 1-800-268-7095 (TTY Canada). Or mail, Private Security and Investigative Services Branch,
25 Grosvenor Street, 12th Floor, Toronto ON M7A 1Y6
Name
Signature Date (yyyy/mm/dd)
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