eConsent Order Form-Rev18Jun22

Disclose Personal Information Form

eCon & VSS Rev 3 - 08Sep25: 221164166489259

For questions or assistance call 902.450.0697 or email csi@csiscreening.com
Company Name*
Company Address
Receipt/Client Account #
B. Applicant Information Section
I HEREBY CONSENT TO THE SEARCH OF THE RCMP NATIONAL REPOSITORY OF CRIMINAL RECORDS BASED ON THE NAME(S), DATE OF BIRTH AND DECLARED CRIMINAL RECORD PROVIDED. I UNDERSTAND THAT THE RESULTS MAY BE TRANSMITTED OUTSIDE CANADA TO MY EMPLOYER FOR EMPLOYMENT PURPOSES. A. Criminal Record (Adult) AUTHORIZATION AND WAIVER Authorization to Release Clearance Report. 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 a Criminal Record to CSI Inc. and its partners. I hereby release and forever discharge all members and employees of the processing Police Service 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 processing Police Service to CSI Inc. and its partners. Information related to this criminal record is collected, retained, and disclosed in accordance with applicable federal, provincial, and municipal privacy legislation. Note: The presence of information does not necessarily mean the applicant will be disqualified from the position by the organization.
I understand, authorize and consent that by using this Electronic Identity Verification (EIV/eConsent) process, my identity will be positively verified electronically and once verified, I consent to the above search. I also understand that by providing the secure personal information used in this process that the positive verification of my identity will also be used as my legal informed consent.
I understand, authorize, and consent that by using this Electronic Identity Verification (EIV/eConsent) process, my identity will be positively verified electronically, and once verified, I consent to the above search. I also understand that by providing the secure personal information used in this process that the positive verification of my identity will also be used as my legal informed consent. PLEASE ensure the information as entered is correct as this is what is used to conduct your criminal record check. If information is entered incorrectly, you will not be refunded and will need to place an order for a new criminal record check.
Yes or No*
Name

First NameMiddle NameLast Name
First Name*
Middle Name
Last Name*
Maiden Name
Street Address*
Apt or Unit Number
Country*
City*
Province/State Region*
ZIP/Postal Code*
Phone Number*
Name Change(If applicable)
Gender*
male or female
Date of Birth - MUST be entered correctly MM-DD-YYYY*

MonthDayYear
Date
Place of Birth
SIN/SSN

Additional Information
C. Self Declaration Section (Required)

(If yes provide all Canadian criminal convictions on the Form B pop-out below. These will be verified) DO NOT LIST ANY OF THE FOLLOWING OFFENCES ON THIS FORM: A conviction for which the Applicant has received a Pardon in accordance with the Criminal Records Act A conviction where the applicant was a “young person” under the Youth Criminal Justice Act An Absolute Discharge or Conditional Discharge pursuant to section 730 of the Criminal Code An offence for which the applicant was not convicted Any provincial or municipal offence Any charges dealt with outside of Canada Declaration of Criminal Record does not constitute a Certified Criminal Record by the RCMP Declaration of Criminal Record may not contain all criminal record convictions A Certified Criminal Record can only be issued by CCRTIS based on the submission of fingerprints to the RCMP National Repository of Criminal Record.
Have you ever been convicted of a criminal offence in Canada?**

YesNo

Signature

Clear
D. Enhanced (Police Information Portal or PIP) Criminal Record Check.

Police Information Check (PIC), also referred to as the "Enhanced", Self Declaration (if requested by Employer)
I understand and consent that by using this Electronic Identity Verification (EIV/eConsent) process, my identity will be positively verified electronically, and I consent to the search. I also understand that by providing the secure personal information used in this process, positive verification of my identity will also be used as informed consent.
Did you order the “Enhanced Canadian Criminal Record Check”?

YESNO
Do you have any outstanding warrants, charges, judicial orders, peace bonds, probation/prohibition orders, or any absolute or conditional discharges? The answer to this and any other questions in Section D, are only applicable if your order includes the Enhanced (Police Information Portal or PIP) Criminal Record Check.

YesNo

E. Application Email Section
E-mail*
example@example.com
Date*

MonthDayYear
Date
Should be Empty:

	Date	Location...............	Charge..............................................................................	Disposition...............
1
2
3
4

	DATE	OFFENCE+(POLICE SERVICE if known)	LOCATION OF OFFENCE
1
2
3
4
5
6
7
8
9

Disclose Personal Information Form

For questions or assistance call 902.450.0697 or email csi@csiscreening.com

Additional Information

C. Self Declaration Section (Required)

D. Enhanced (Police Information Portal or PIP) Criminal Record Check.

E. Application Email Section