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A. Personal Information: Criminal Record Verification Informed Consent Form

This document contains an informed consent form for a criminal record verification. The applicant, Shaharul Islam, provides personal information and consents to Mintz Global Screening searching criminal records databases on his behalf for employment purposes with Xplornet Communications. The applicant acknowledges the limitations of the record search and provides authorization and a waiver allowing the results to be released to the screening company and employer. The applicant's identity is verified before signing to consent to the criminal record check.

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361 views1 page

A. Personal Information: Criminal Record Verification Informed Consent Form

This document contains an informed consent form for a criminal record verification. The applicant, Shaharul Islam, provides personal information and consents to Mintz Global Screening searching criminal records databases on his behalf for employment purposes with Xplornet Communications. The applicant acknowledges the limitations of the record search and provides authorization and a waiver allowing the results to be released to the screening company and employer. The applicant's identity is verified before signing to consent to the criminal record check.

Uploaded by

shaharul islam
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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CRIMINAL RECORD VERIFICATION

Informed Consent Form

A. Personal Information
Surname (last name): ISLAM Given names(s): SHAHARUL
Surname (last name) at birth: Former name(s):
Place of birth(City, Province/State, Country): DHAKA,BANGLADESH
Date of Birth (YYYY-MM-DD): 1983-03-03 Sex(check one) Female Male
Phone number(s): (506) 230-9002 Email address: shaharul007@gmail.com
Current Home Address
517 PRIESTMAN STREET F4 FREDERICTON NEW BRUNSWICK E3B3B6
Number Street Apartment City Province/Territory/State Postal/ZIP code

Previous Address(es) Within the Last 5 Years (attach additional page if necessary)

2491 LINCOLN ROAD FREDERICTON NEW BRUNSWICK E3B7E6

43/4 WEST VASANTEK 3F DHAKA BD 1206


B. Reason for the Criminal Record Verification
Reason for Request (example: Employment – Employer – Job Title): Employment
Organization Requesting Search: XPLORNET COMMUNICATIONS INC
Contact Name: SUE CORLISS Contact Phone Number: 5034522780
C. Informed Consent

SEARCH AUTHORIZATION – I HEREBY CONSENT TO THE SEARCH OF the RCMP National Repository of Criminal Records based on the name(s), date of birth and where
used, the declared criminal record history provided by myself. I understand that this verification of the National Repository of Criminal Records is not being confirmed by
fingerprint comparison which is the only true means by which to confirm if a criminal record exists in the National Repository of Criminal Records.

POLICE INFORMATION SYSTEM(S) – I HEREBY CONSENT TO THE SEARCH OF police information systems, as part of a Police Information Check, which will consist of a search
of the following systems (check applicable):
CPIC investigative Data Bank Police Information Portal (PIP)
OTHER

AUTHORIZATION AND WAIVER to provide a confirmation of criminal record or any police information.

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 the results of the criminal record
checks to Mintz Global Screening Inc. in Toronto, CA. and XPLORNET COMMUNICATIONS INC In WOODSTOCK,CA.

I hereby release and forever discharge all members and employees of the processing Police Service and the Royal Canadian Mounted Police 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 Cobourg
Police Service to Mintz Global Screening Inc. Toronto, CA. and XPLORNET COMMUNICATIONS INC, WOODSTOCK,CA.

Signature of Applicant DATE Signed at


YYYY-MM-DD
2020-03-20 FREDERICTON NEW BRUNSWICK

D. Identification Verification Physical Identity Verification Electronic Identity Verification

Witnessing Agent’s Name: Identification Verified:

Type of Photo ID Viewed


Witnessing Agent’s Signature:
(Government Issued) & Secondary ID

Name and location of the company where information will be stored in Canada: Mintz Global Screening, 1303, Rue William, Montréal, QC

** Information related to this criminal record check is collected, retained and disclosed in accordance with applicable privacy legislation. **

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