APPLICANT INFORMATION Given name(s)

Surname(s) Maiden name(s)

Place of birth (if born outside of Canada, indicate date of entry to Canada)

-

Date of birth YYYY

MM

j Gender M/F

DD

lelephone Number (s)

Drivers license number

-.

I

LIST ALL PLACES OF RESIDENCE DURING THE LAST FIVE (5) YEARS Street No.

-

Street Name

Apt No.

Province! Territory, Country

Postal Code

FROM YYYY-MM

TO YYYY-MM

* DO NOT FORGE ITO ATTACH TWO PIECES OF IDENTIFICATIONS WITH YOUR APPLICATION* Social Insurance Number (SIN) is not acceptable for identification purposes

PIECE OF IDENTIFICATIONS

-

IDENTIFICATION #1

FULL NAME

IDENTIFICATION #

IDENTIFICATION #2

FULL NAME

IDENTIFICATION #

VERIFIED BY Representative Signature

Representative Name

APPLICANT CONSENT I HEREBY CONSENT TO THE FOLLOWING VERIFICATIONS: A. B. C. D. E.

Criminal Records Search (Adult) Credit Bureau Report Employment verification Education! Professional Accreditation Personal Reference Verification

SEARCH AND DISCLOSURE CONSENT 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 criminal record information based on name and date of birth from the RCMP National Repository of Criminal Records to Gardium Sécurité to disseminate and transmit the results electronically or in hard copy to a location inside Canada. The information is collected and disclosed according to municipal, provincial and federal privacy laws. I hereby release and forever discharge all members and employees of Gardium Sécurité 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 Gardium Sécurité. I also acknowledge that the disclosed information may only be confirmed by a comparison of my fingerprints to those on file.

Signed this

day of the month of

20 Signature

Note: The presence of information does not necessarily mean the applicant will be disqualified from the position by the organization. Rev. 2016-02-09

UCO Operations 2016, Canadian Criminal Background Verification ...

Page 1 of 1. APPLICANT INFORMATION. Surname(s) Given name(s). Maiden name(s) - Place of birth (if born outside of Canada, indicate date of entry to Canada). Date of birth. YYYY MM DD. j Gender. M/F. lelephone Number (s). I. Drivers license number -. LIST ALL PLACES OF RESIDENCE DURING THE LAST FIVE (5) ...

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