Consent to a Criminal Record Check Form

This form is for current Comox Valley School employees working with children an/or vulnerable adults

Personal Information

Legal Name:(Required)

First Middle Last

Date of Birth:(Required)

Birthplace:(Required)

Gender:(Required)

Male

Female

X

Additional Names

Would you like to add additional names? (Alias, Maiden Name, etc.)(Required)

Yes

No

Additional Names #1: (optional)

First Middle Last

(Alias, Maiden Name, etc.)

Would you like to add additional names? (Alias, Maiden Name, etc.)(Required)

Yes

No

Additional Names #2: (optional)

First Middle Last

(Alias, Maiden Name, etc.)

Residential Address:(Required)

Street Address Address Line 2 City Province Postal Code

Is there a mailing address different from the above residential address?(Required)

Yes

No

Mailing Address:(Required)

Street Address Address Line 2 City Province Postal Code

Contact Phone Number:(Required)

Email:(Required)

Government Issued Photo ID Number:(Required)

Consent for Release of Information and Acknowledgements

The information requested on this form is collected under the authority of the Criminal Records Review Act section 4(1) and section 26(c) of the Freedom of Information and Protection of Privacy Act (FOIPPA). The information provided will be used to fulfil the requirements of the Criminal Records Review Act for the release of criminal records information and is in compliance with the FOIPPA.

If you have questions about the collection of your personal information, please contact the Policy Analyst, Criminal Records Review Program, PO Box 9217 Stn Prov Govt, Victoria, BC, V8W 9J1 or by phone at to 1-855-587-0185.

I have read and understand the Consent for Release of Information and Acknowledgements listed above and I herby consent to these terms as indicated by my signature below.

Applicant Signature(Required)

Put your signature in the box above

Comments

This field is for validation purposes and should be left unchanged.

Consent to a Criminal Record Check Form – Current Employees

Consent to a Criminal Record Check Form

Personal Information

Additional Names

Consent for Release of Information and Acknowledgements

COMOX VALLEY SCHOOLS