LASALLE POLICE SERVICE

POLICE VULNERABLE SECTOR CHECK

Level 3

(This search ISintended for persons working with children or the vulnerable sector)

Applicant’s information (PLEASE PRINT CLEARLY)Date of Request:

______

Last NameFirst NameMiddle Name

Maiden Name (name used before marriage)Other names

Address Phone number

CityProvince / Postal CodeDate of Birth (dd / mm / yyyy)Gender

List any other addresses where you have lived in the last 5 years.

1.

2.

3.

Reason for Request (state below) Self Declaration of Criminal Record

( ) VOLUNTEER ( ) EMPLOYMENT ( ) OTHER ( ) ATTACHED ( ) NO RECORD

1.______Position: ______

2. ______Position: ______

3. ______Position: ______

______

CONSENT – Please initial each one after you have read it

  1. I consent to a search being made in the automated criminal records retrieval system maintained by the Royal Canadian Mounted Police to find out if I have been charged and/or convicted of any criminal offences. The LaSalle Police Service or authorized body will then disclose that information to me.______
  1. I hereby release and discharge the LaSalle Police Service and all their agents from any and all claims, actions and demands for damages, loss or injury of any nature arising from disclosure of information. I hereby authorize the LaSalle Police Service to inquire into and conduct searches Canada wide and disclose to myself details of this information assist an agency/organization in making an informed decision concerning my application. Furthermore, I understand that upon the disclosure of information, the LaSalle Police Service and all their agents waive any responsibility for its use and or subsequent dissemination by myself.______
  1. NOTICE TO APPLICANT: YOU MUST RETURNAND SIGN THE POLICE CLEARANCE LETTER WITHIN 30 DAYS OF ISSUE OR THE LETTER WILL BE DEEMED OBSOLETE. NO REFUND WILL BE GIVEN FOR OBSOLETE LETTERS. ______
  1. I certify that the information provided by me in this application is true and correct to the best of my knowledge and belief. I have read this consent, understand it and agree to it in it’s entirety.______
  1. I consent to a search being made in the automated criminal records retrieval system maintained by the Royal Canadian Mounted Police to find out if I have been convicted of, and/or been granted a pardon for, any of the sexual offences that are listed in the schedule to the Criminal Records Act. I also agree to a search of the Sexual Offenders Registry.______
  1. I understand that, as a result of giving this consent, if I am listed on the sexual Offenders Registry or suspected of being the person named in a criminal record for one of the sexual offences listed in the schedule to the Criminal Records Act in respect of which a pardon was granted or issued I may be asked to sign a consent and submit fingerprints for verification to the RCMP. The Commissioner of the Royal Canadian Mounted Police may then provide that record to the Solicitor General of Canada, who may then disclose all or part of the information contained in that record to a police service or other authorized body. That police force or authorized body will then disclose that information to me.______

SIGNATURE OF APPLICANT: ______DATE: ______, 20______

APPEAL PROCESS – If an applicant wishes to appeal the information that has been released on their POLICE VULNERABLE SECTOR CHECK, the applicant shall submit a written request with supporting documents (if any) within seven business days of receiving the Police Vulnerable Sector Check. This must be done via letter indicating what information they feel should be removed and the reasons for requesting its’ removal from the Police Vulnerable Sector Check.

IDENTIFICATIONCONFIRMED BY: ______DATE: ______

Personal information contained on this form is collected pursuant to the Municipal Freedom of Information and Protection of Privacy Act, S28(2), s32(b) and the Police Services Act, S41 for the purpose of processing this police record check. Questions concerning this information should be directed to LaSalle Police Service, Police Clearance coordinator unit, 1880 Normandy Street, LaSalle, Ontario N9H 1P8.

POLICE USE ONLY

***********Attach all print outs**********

□LEVEL III Police Vulnerable Sector Check (PVSC)

CPIC Checks: 10-29□ No Record□ Record

CNI□ No Record □ Record

RMS: □No Occurrences □ Occurrences

Dispatch History: □No Occurrences □Occurrences

Drivers Licence Checks: □Valid DL □Address History □Need to contact other Agency

SOR: □ No Record □ Record

Queried by:______Date:______