Saskatchewan Provincial Court Judicial Council

Consent for Disclosure of Personal Information

Surname: / Gender: / £ Male / £ Female
Given names in full:
Surname at birth:
Do you use any other names (maiden, alias, nickname, other)? / £ Yes / £ No
If yes, please provide these names:
Date of birth:
Place of birth (city, province/state, country):
Current home address:
Previous home address:
(if at current address for less than two years)
Home telephone number:
Social Insurance Number:
Driver’s license number and province of issue:
I understand that checks of my background are required to determine my suitability for a judicial appointment. The information obtained in these checks will be communicated to the Saskatchewan Provincial Court Judicial Council and the Minister of Justice. This information will be held in confidence and used solely for the purposes of assessing my suitability for appointment.
Pursuant to the Privacy Act, R.S.C., 1985, c. P-21, ss.7-8; The Privacy Act, R.S.S. 1978, c. P-24, s.4(1)(a); and The Freedom of Information and Protection of Privacy Act, S.S.1990-91, c. F-22.01, s. 29(1), I consent to the disclosure of the above information as required for the purpose of determining my suitability for an appointment, and to the disclosure of the results of such background checks to the Saskatchewan Provincial Court Judicial Council, any of its members or authorized agents, and the Minister of Justice.
I hereby signify my consent as set out above and certify that the information set out by me on this page is true and correct to the best of my knowledge and belief. I understand that a false statement may disqualify me from consideration for appointment.
These background checks will include the following elements:
·  A check by the Royal Canadian Mounted Police of police records relating to me, including, where applicable, enquiries with provincial police services and municipal police services. Police records include information related to criminal charges and/or convictions, details surrounding an offence, or information concerning a person’s involvement in criminal activity.
·  A check with the Canada Revenue Agency (CRA). The CRA will indicate with a ‘yes’ or ‘no’, without providing details, whether there are any significant compliance-related issues relating to me under any Act administered in whole or in part by the CRA.
·  A check with the Office of the Superintendent of Bankruptcy to determine if my name appears in its bankruptcy and insolvency databases.
·  A check with Saskatchewan Government Insurance and similar agencies in other provinces to compile a driver’s abstract in those jurisdictions where I hold a valid driver’s licence.
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Signature / ______
Date