Informed Consent Form
A. Personal Information
Surname (last name):
Given names(s):
Surname (last name) at birth:
Former name(s):
Place of birth (City, Province/State, Country):
Date of birth (YYYY-MM-DD):
Sex (check one) Female Male
Phone number(s):
Email address:
Current Home Address
Postal/ZIP code
Previous Address(es) Within the Last 5 Years (attach additional page if necessary)
B. Reason for the Criminal Record Verification
Reason for Request (example: Employment Employer Job Title): Employment
Organization Requesting Search: Maxsys Staffing and Consulting
Contact Name:
Contact Phone Number:
C. Informed Consent
SEARCH AUTHORIZATION I HEREBY CONSENT TO THE SEARCH OF the RCMP National Repository of Criminal Records based on the name(s), date of birth and where used,
the declared criminal record history provided by myself. I understand that this verification of the National Repository of Criminal Records is not being confirmed by
fingerprint comparison which is the only true means by which to confirm if a criminal record exists in the National Repository of Criminal Records.
POLICE INFORMATION SYSTEM(S) I HEREBY CONSENT TO THE SEARCH OF police information systems, as part of a Police Information Check, which will consist of a search of
the following systems (check applicable):
CPIC investigative Data Bank Police Information Portal (PIP)
AUTHORIZATION AND WAIVER to provide a confirmation of criminal record or any police information.
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 the results of the criminal record checks
to Mintz Global Screening Inc. and Maxsys Staffing and Consulting located in located in Toronto, Canada and Ottawa, Ontario
Company Name City and Country
I hereby release and forever discharge all members and employees of the processing Police Service and the Royal Canadian Mounted Police 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
Cobourg Police Service to Mintz Global Screening Inc. and Maxsys Staffing and Consulting, Toronto, Canada and Ottawa, Canada.
Name of Processing Police Service Company Name City and Country
Signature of Applicant
Signed at
Year Month - Day
D. Identification Verification
Physical Identity Verification
Electronic Identity Verification
Witnessing Agent’s Name:
Identification Verified: Yes
Witnessing Agent’s Signature:
Type of Photo ID Viewed
(Government Issued) & Secondary ID
Name and location of the company where information will be stored in Canada: Mintz Global Screening Inc., Montreal, Quebec
**Information related to this criminal record check is collected, retained and disclosed in accordance with applicable privacy legislation. **
Date de version du formulaire: 2017-10-05 Cobourg Police Service
Declaration of Criminal Record Form
Declaration of Criminal Record
This form is required to be filled and attached to your Informed Consent Form for a Criminal Record Verification.
Surname (last name) ______________________ Given name(s) ______________________ Date of Birth: __________
Information is collected and disclosed in accordance with federal, provincial and municipal laws.
A Declaration of Criminal Record does not constitute a Certified Criminal Record by the RCMP and may not contain all criminal
record convictions.
Applicants must declare all convictions for offences under Canadian federal law.
Do not declare the following:
- A conviction for which you have received a Record Suspension (formerly pardon) in accordance with the Criminal Records Act;
- A conviction where you were a “young person” under the Youth Criminal Justice Act;
- An Absolute or Conditional Discharge, pursuant to section 730 of the Criminal Code;
- An offence for which you were not convicted;
- Any provincial or municipal offence, and;
- Any charges dealt with outside of Canada.
Note that a Certified Criminal Record can only be issued based on the submission of fingerprints to the RCMP National
Repository of Criminal Records.
Date of Sentence
Court Location
_________________________________________________ _________________
Signature of Applicant Date (YYYY-MM-DD)
Verified By:
Name of Police Agency Employee
Signature of Police Agency Employee
All applicants for a criminal record check must provide government-issued identification prior to undergoing a name-based
criminal record check. Legible copies of the identification must be included with the authorization form.
An applicant must provide copies of two (2) pieces of valid identification, one of which must be government-issued and include
the applicant’s name, date of birth, signature and photo of the applicant. Copies of the identification documents must be certified
by a witness who will confirm that the applicant signing the informed consent is the individual on the government-issued
identification. The witness verifying the identity of the applicant must compare the signature on the government-issued
identification to the signature on the Informed Consent form.
One of the provided pieces of identification must be one
of the following:
The second piece of ID can be another photo ID from the
previous list or can be any of the following:
Driver’s Licence (issued by Canadian province or
territory) or Nexus Card
Foreign Driver’s Licence
Photo Health Card (except in Ontario, Manitoba or
Prince Edward Island)
Canadian Passport
Foreign Passport
Canadian Citizenship Card
Permanent Resident (PR) Card
Certificate of Indian Status
Firearms Acquisition Certificate (FAC)
Federal, Provincial or Municipal Identification Card
Military Family Identification Card (MFID)
Birth Certificate
Baptismal Certificate
Hunting Licence
Fishing Licence
Outdoors Card
Hospital Card
Immigration Papers
Canadian Blood Donor Card (only if date of birth
Student Identity Card (as long as name is shown)
The witness must personally view the identification provided and ensure that it matches the person signing this form. The witness
may be contacted as part of an audit of this process to verify that this occurred.
The witness must be one of the following:
An employee of the company for which this background screening is being completed or;
A duly authorized and licensed notary public or;
An independent arms length witness. This is defined as a person who is not related by marriage or blood to the candidate or
otherwise in an intimate relationship. The witness must be at least 18 years of age and have known the candidate personally
for a minimum of 2 years. To know an applicant personally means that the witness is able to confirm aspects of the applicant's
personal attributes such as name, approximate age, place of birth, physical description and some personal history.
Note to Applicant: You may make a request for access to your personal information, a request for correction or any other request for information
by sending a written request to Mintz (Mintz Global Screening 1303 William Street, Suite 200, Montréal, QC, H3C 1R4 to the attention of Privacy
Officer. Mintz will answer your request for access, correction or information within thirty (30) days following its reception.
Prior to undergoing a name-based criminal record verification, you can self-declare the content of your criminal record using the
Declaration of a Criminal Record form available on the next page. The police will compare the data provided against their
database and determine either the declaration is:
Complete: there are no other criminal record convictions than the ones declared and the information provided is
accurate or your declaration is considered by the police service a material representation of your criminal history.
Incomplete: the information provided is inaccurate or it is not a complete listing of the applicant’s criminal record.
The confirmation of a declaration of a criminal record does not constitute a Certified Criminal Record by the RCMP-GRC. A
Certified Criminal Record can be only issued based on the submission of fingerprints to the RCMP National Repository of Criminal
Records. Also note that the confirmation of a declaration of a criminal record may not contain all criminal record convictions.
1. Using the form provided on the next page, enter your name and date of birth exactly as they appear on your background
screening consent form.
2. Enter one criminal charge per line. If you were convicted for several counts at the same time, please use one line per
3. Identify the offence, date of conviction, and court location where the judgment was rendered.
All convictions for criminal offenses under federal law.
Absolute discharges or conditional discharges, pursuant to the Criminal Code, section 730.
Any charges for which you have received a record suspension (“pardon”), pursuant to the Criminal Records Act.
Any offences while you were a “young person” (twelve years old but less than eighteen years old), pursuant to the Youth
Criminal Justice Act.
Any charges for which you were not convicted, for example, charges that were withdrawn, dismissed, etc.
Any provincial or municipal offences, for example traffic infractions.
Any charges dealt with outside of Canada.
Any charges for which you received a stay of proceedings.