Full-Drivers-Application - Transemerge

Application Form (for AZ Contract Drivers)

Full-Drivers-Application – Transemerge

Step 1 of 7

Accident records for the past three years

Date

Nature of Accident (Head-on, Rear end, upset, NAF ect)

Fatalities

Injuries

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Traffic convictions and forfeitures for the past three years (other than narklnz violations)

Date

Location

Charge

Penalty

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License Information – Driver

Drivers License

State

License Number

Type

Exp. Date

Drivers License

State

License Number

Type

Exp. Date

1. Have you ever been denied a license, permit or privilege to operate a motor vehicle.

Yes

2. Has any license, permit or privilege ever been suspended or revoked.

Yes

If answer to any the question above is YES, please attach a separate sheet giving detailed explanation.

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Class of Equipment

Type of Equipment

Date

From – To

Approx Total Miles

List the states operated in for the last five Years:

List Special Courses or training that will help you as a driver:

Canadian Hours of Service
Driver Statement of On-Duty Hours
(For Newly Hired Drivers)

INSTRUCTIONS: Motor carriers when using a driver for the first lime or intermittently shall obtain from the driver a signed statement giving the driver’s total time on –duty during the immediately preceding 14 days and time at which such driver was last relieved from duty prior to beginning work for such carrier (see Section 395.8(j)(2) Federal Motor Carrier Safety Regulations). NOTE: Hours for any compensated work during the preceding 14 days, including work for a non• motor carrier entity, must be recorded on this forn.

Driver Name

SIN

Driver License#

Prov/State

Day	1	2	3	4	5	6
Hours

I hereby certify that the information given is correct to the best of my knowledge and belief, and that I was last

Signature

Date

List Two persons for references, other than family members who know your safety habits.

Name

Address

Phone

Name

Address

Phone

To be read and signed by the applicant

This certifies that I

completed this application and that all entries and all information

provided is true tom the best of my knowledge.

I authorize

and any of its employees and affiliates to make such investigations

and enquiries on my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. (Generally inquiries regarding medical history will be made only and if a conditional offer of employment has been extended). I hereby release employers, schools, health care providers and other persons from all liabilityin responding enquiries and releasing information in connection with my application.\
In the case of employment I understand that false and misleading information given in my application or interview(s) may result in discharge. I also understand that I am required to abide my all rules and regulations of Trans Emerge Transport Inc.
It is understood that company incurs a considerable expense during the hiring process. In consideration of the hiring cost I hereby commit to work for Trans Emerge Transport Inc. for a minimum period of SIX months. If I leave before SIX months the company will have right to deduct the hiring cost from my paycheck. The amount of such deduction (hiring cost) is at the sole discretion of the company but will not exceed CAN$1000.00

Signature

Date

Applicant Hired

Yes

Date of Hiring

Termination

Quit

Terminated

Department released from

Certification of Compliance with Driver License Requirements

MOTOR CARRIER INSTRUCTIONS: The requirements in Part 383 apply to every driver who operates in intrastate, interstate, or foreign commerce and operates a vehicle weighing 26,001 pounds or more, can transport more than 15 people, or transports hazardous materials that require placarding.
The requirements in Part 391 apply to every driver who operates a vehicle weighing 10,001 pounds or more, can transport hazardous materials that require placarding.
DRIVER REQUIREMENTS: Parts 383 and 391 of the Federal Motor Carrier Safety Regulations ccntain some Requirements for the driver’s license effect as of July 1, 1987. They are as follows:
1) POSSESS ONLY ONE LICENSE: You, as a commercial vehicle driver, may not possess more than one motor vehicle operator’s license. If you currently have more than one license, you should keep the license from your state of residence and return the additional licenses to the states that issued them. DESTROYTNG a license does not close the record U1 that state that issued it; you must notify the state. If a multiple license has been lost, stolen, or destroyed, you should close your record by notifying the state of issuance that you no longer want to be licensed by that state.
2) NOTIFICATION OF LICENSE SUSPENSION, REVOCATION OR CANCELLATION: Sections 392.42 and 383.33 of the Federal Motor Carrier Safety Regulations require that you notify your employer the next business day of any revocation or suspension of your driver’s license. ln addition, Section 383.3 I requires that any time you violate a state or local traffic law (other than parking), yon must report it to your employing motor carrier and die state that issued your license within 30 days (if the violation occurs in a state other than the one which issued your license). The notification to both tho employer and state must be in writing.
Driver Certification: I certify that I have read and understood the above requirements. The following license is the only one I possess:

Driver's License No

State

Exp. Date

Name

Signature

Date

DRIVER’S RIGHTS PERTAINING TO RELEASE OF DRIVER
INFORMATION UNDER REGULATIONA 391.23

Motor carriers have the responsibility to make the following investigations and inquiries with respect to each driver employed, other than a person who has been a regularly employed driver of motor carrier for a continuous period which began before January 1, 1971.
*(a)(l) An inquiry into the driver’s driving record during the preceding three years to the appropriate agency of every State in which the driver held a motor vehicle operator’s license or permit during those three years. *(a)(2) an investigation of the driver’s employment record during the preceding three years. *(b) A copy of the driver record(s) obtained in response to the inquiry or inquiries to each State driver record agency as required must be placed in the Driver Qualification File within 30 days of the date the driver begins work and be retained in compliance with 391.51.
*(c) Replies to the investigations of the driver’s safety performance history must be placed in the Driver Investigation History File within 30 days of the date the driver begins work. This goes into effect after October 29, 2004. *( d) Prospective motor carrier must investigate the information from all previous employers of the applicant that employed the driver to operate a CMV within the previous three years. This information must cover general driver identification and employment verification information, data elements as specified in 390.15 for accident involving the driver that occurred in the three-year period preceding the date of this application and any accidents the previous employer may wish to provide. *(e) Prospective motor carrier must investigate the information from all previous DOT regulated employers that employed the driver within the previous three years from the date of the employment application an a safety sensitive function that required alcohol and controlled substance testing specified by 49 CFR Part 40.
Drivers have the following rights:
1. The rigbt to review information provided by previous employers.
2. The right to have errors in the information corrected by the previous employer and for that previous employer to resend the corrected information to the prospective employer.
3. The right to have a rebuttal statement attached to the alleged erroneous information, if the previous employer and driver cannot agree on the accuracy of the information.
Drivers who wish to review previous employer-provided investigative information must submit a written request to the company when applying or as late as 30 days after start of work or being notified of denial of acceptance of this application. The company must provide this information to the applicant within 5 business days of receiving the written request. If the driver has not arranged to pick up or receive the requested records within 30 days of the companymaking them available. The prospective motor carrier may consider the driver to have waived his/her request to review the records.
Drivers wishing to request correction of erroneous information in records must request for the correction to the previous employer that provided the records. After October 29, 2004, the previous employer must either correct and forward the information to the prospective motor carrier or notify the driver within 15 days of receiving the driver’s request to correct the data that does not agree to correct the data. Drivers wishing to rebut information in records must send the rebuttal to the previous employer with instruction to include the rebuttal in the driver’s Safety Performance History.
I acknowledge that [ have read and understood the contents of the document.

Driver's Signature

Driver Name:

Date

MOTOR VECIDCLE DRIVER’S CERTIFICATION OF
VIOLATIONS/ANNUAL REVIEW OF DRIVING RECORD

MOTOR CARRJER INSTRUCTIONS: Bach motor carrier shall at least once every 12 months, require each driver that works for it to prepare and furnish it with a list of all violations of motor vehicle traffic laws and ordinances (other than violations involving only parking) of which the driver has been convicted, or on account of which he/she has forfeited bond or collateral during the preceding 12 months (Section 391.27). Drivers who have provided information required by Section 383.31 need not repeat that information on this form.
DRIVER REQUIREMENTS: Each driver shall furnish the list as required by the motor carrier above. If the driver has not been convicted of, or forfeited bond or collateral on account of any violation which must be listed, he/she shall so certify (Section 391.27).

COMPLETED BY DRIVER- CERTIFICATION OF VIOLATIONS

Name of Driver:

Social Insurance Number:

Driver's License Number:

State:

Expiration Date

I certify that the following is a true and•complete list of traffic violations required to be listed (other than those I have provided under Part 383) for which I have been convicted or forfeited bond or collateral during the past 12 months.

(If you have had no violations, check the box and sign

First Choice

Date

Offense

Location

Type Of Vehicle Operated

If no violations are listed above, I certify that I have not been convicted or forfeited bond or collateral on account of any violation (other than those I have provided under Part 383) required to be listed during the past 12 months.

Driver's Signature

Date

COMPLETED BY MOTOR CARRIER-ANNUAL REVIEW OF DRIVING RECORD

MOTOR CARRJER INSTRUCTIONS: Review the Certification of Violations listed above and other information described in Section 391.25 of the Federal Motor Carrier Safety Regulations. Complete the information requested below. I have hereby reviewed the driving record of the above named driver in accordance with Section 391.25 and find that he/she (check one): DMeets minimum requirements for safe driving Dls disqualified to drive a motor vehicle pursuant to Section 391.15 LI Does not adequately meet satisfactory safe driving performance

Action taken with driver

Reviewed by:

Name

Signature

Title

Date

Previous Employer/Company Referral Check Request Form

Last Middle First

authorize the Previous Employer:

Social Insurance Number

Street

Telephone

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City

Province

Postal Code

Fax No

may release and forward information requested by section 2 (below) of this document concerning my Alcohol and Controlled Substances Testing Records to
Prospective New Company: Trans Emerge Transport Inc.
Street: I 574 Engle St. N

City, Province, Postal Code: Cambridge ONT

Telephone: (519)621-9595 Fax No: (289)207-1544

In compliance with §40.25 (g), release of this information must be made in a written fonn that ensures confidentiality, such as fax, e-mail, or letter.

Trans Emerge Email: safetyteam@transemerge.com

Driver's Signatures

Date

Applicant Drug Testing Notice
The company is committed both to maintaining a safe and efficient workplace that is free of drugs and alcohol, and to discouraging drug, alcohol and substance abuse by its workers. In accordance with this commitment and in compliance with The Modesto Bee’s Drug, Alcohol and Substance Policy, continued engagement is contingent upon adhering to the policy. This includes cooperating with Reasonable Suspicion Drug Testing.
In the event of Reasonable Suspicion testing, drivers will be asked to sign an acknowledgement and consent form and to provide a urine sample to The Modesto Bee-appointed medical staff for the drug test and/or submit to a breath analyzer test. Refusal to sign the acknowledgment and consent or submit to a drug and/or alcohol test will be treated the same as a positive result.\
Test samples will be sent to an independent National Institute of Drug Abuse (NIDA)-certified medical clinic or laboratory for processing. All test results will then be read and interpreted by a Modesto Bee – appointed, Medical Review Official (MRO)-certified physician. Positive test results will be confirmed by a gas chromatography/mass spectrometry the company will pay the cost of the first drug test and for the confirmation of a positive test result. If a driver disagrees with a confirmed positive test result, the driver may have the same sample sent to a NIDA-certified lab to be tested at his other own expense. This request must be made in writing within two days of being advised of a positive test result.
The offer of contract/work will be revoked if you test positive. If you test positive, you will not be eligible to reapply with the Company for at least twelve months from the date of the last drug test. All drug-testing records are kept confidential. Access to such information is limited to individuals who have a business need to know.
I understand that ifl receive an offer of contract/work from Trans Emerge Transport Inc., the offer will be contingent upon successful completion of a urine drug screen.
Signature
Date
MM slash DD slash YYYY

Prospective Driver's Nmne
SIN#
Alcohol and Drug Driver’s Certified Receipt
Prospective Driver's Name:
First
SIN#
This is to certify that I have been provided educational materials required by §382.601 and new company’s policies and procedures with respect to meeting the Part 382 requirements. The materials include detailed discussion of the following checked items:
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The designated person to answer questions about the materials
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The categories of drivers subject to Part 382
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Sufficient information about the safety-sensitive functions and periods of the workday that compliance is required
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Specific information concerning prohibited driver conduct
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Circumstances under which a driver will be tested
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Test procedures, driver protection and integrity of testing processes, and safeguarding the validity of the test
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The requirement that tests are administered in accordance with Part 382
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An explanation of what will be considered a refusal to submit to a test and the consequences
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The consequences of Part 382 Subpart B violations including removal frorn safety-sensitive functions and Part40 Subpart O procedures
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The consequences for drivers found to have an alcohol concentration of0.02 or greater but less than 0.04
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Information on the affects of alcohol and controlled substances use on:
– an individual’s health – signs and symptoms of a problem – work-personal life – available methods of intervening when a problem is suspected
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Optional information
Driver's Signatures
Date
MM slash DD slash YYYY

Authorized Company Representative
Date
MM slash DD slash YYYY

Pre-Employment Alcohol and Drug Test Statement
Sec. 40.25 (j) As the employer, you must also ask the employee whether he or she has tested positive, or refused to test, on any pre-eruployrnent drug or alcohol test administered by an etnployer to which the employee applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years. If the employee admits that he or she bad a positive test or ti refusal to test, you must not use the employee to perform safety sensitive functions for you, until and unless the employee documents successful completion of the return-to-duty process. (see Sec. 40.25(b)(5) and (e))
Company Name
Street
City
Province /Postal
Prospective Employee Name:
Driver's License#
The prospective new driver is required by Sec. 40.250) to respond to the following questions.
Have you ever tested positive. or refused to test. on any pre-employment drug or alcohol test administered by an employer to which you applied for, but did not obtain, safety-sensitive transportation work covered by DOT agency drug and alcohol testing rules during the past two years?

Yes

No
If you answered YES, can you provide/obtain proof that you've successfully completed the DOT return-to-duty requirements?

Yes

No
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Driver's Signatures:
Date
MM slash DD slash YYYY

Witnessed By:
Date
MM slash DD slash YYYY

Medical Declaration
Date:_��=-• (OO’MMIYYYYJ On March 30, 1999, United States Federal Motor Carrier Safety Regulations medical requirements for Canadian drivers of commercial vehicles operating in the Unites States were revised. I acknowledge there is no requirement for a completed United States medical fitness report. This revision does require that a Canadian driver must comply with the medical requirements of the province in which their commercial driver’s license is issued and that a medical fitness report is completed on the frequency by license issuing province.
I
, certify that under the new revisions of the medical requirement to operate a commercial motor
in the United States, that I run not impaired to operate a commercial motor vehicle by any of the following:
A. 1 have no established medicaJ history or clinical diagnosis of diabetes mellitus currently requiring insulin for control (administered by injection).
B. 1 have no established medical history or clinical diagnosis of epilepsy.
C. l have no impaired hearing, first perceives a forced wbispered voice in the better ear at not less than 5 feet with or without use of a hearing aid when the audiometric device is calibrated to American National Standard (fonnerly ASA Standard) 224.5-1951.
I also agree to inform THE COMPANY should my medical status change, and if any of the above impairments arc subsequently diagnosed to the level of affecting my fitness to operate a commercial motor vehicle in the United States.
Driver's Signatures:
Date
MM slash DD slash YYYY

Witness:
Date
MM slash DD slash YYYY

Driver’s Receipt
I acknowledge receipt of the following from
Driver signature required for each item received
Company Policy Manual:
Date
MM slash DD slash YYYY

Controlled Substance Policy:
Date
MM slash DD slash YYYY

FMCSR Handbook:
Date
MM slash DD slash YYYY

TDG Handbook:
Date
MM slash DD slash YYYY

Fuel Card
Date
MM slash DD slash YYYY

Gate Key
Date
MM slash DD slash YYYY

I agree to familiarize myself with all information within
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days
Drivers Name:
Drivers Signature:
Date
MM slash DD slash YYYY

Company Rep. Signature:
Date
MM slash DD slash YYYY

Undertaking
It is hereby understood and agreed that the relationship created by this application is not one of principal and agent, or master and servant, or employer and employee and that in all matters pertaining to this application and the nature of the relationship of the parties hereto, the applicant shall be an independent contractor. The applicant covenants and agrees that be/she will not at any time enter into any contract, agreement whatsoever for or on behalf of the Company or do any other act or thing which would result in the Company incurring any liability or responsibility in respect of the Business other than those contemplated by this application.
Driver's Signatures:
Date
MM slash DD slash YYYY

Witness:
Date
MM slash DD slash YYYY

Consent for the release of personal information
I
have applied for employment/ contract work with Trans Emerge
(The Company). I understand that as a condition of my employment/contract work, the company will perform a full background check on me. These checks/searches may Include some, or all the follovAng: coimlnaf search. drivers abstract driver insurance history, credit history, employment verification, education verification. verification of address for up to 10 years, employment references, Verification of Drivers license status, Terrorism watch list check, Validation of SIN number.
I hereby authorize the holder(s) of Information, relating to the Items checked off below, to disclose the Information requested, at any time, to the company and/or its authorized agents and ISB Canada.
1 understand that the Company will use some or aU the disclosed information provided, from any source to evaluate me and confirm my suitability for employment/contract work.
I hereby release and forever discharge the holder(s) of lnfomnation relating to the above, includin_g !SB Canada, and the Company, their respective affiliated entities and any former. current and future partners, dlrectors, officers, employees, agents, successors and assigns, including those belonging to affiliated entities, from any actions, claims, and demands of any kind whatsoever relating to the collection, disclosure, or use of this iniormalion by the holder(s) of information relating to the above Items, !SB Canada or the Company. I further declare the infomnation below, on my resume/application, and provided verbally to the Company, is complete and accurate. I understand a false statement may disqualffy me from employment and give cause for my dismissal if employed.
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Fraud Alert – through-Equifax Canada
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Driver Record/AbstracVCVOR/NSC – Province
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Address Verification (up to 10years) – through Equifax Canada
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Driver jnsurance History
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SIN Validation – SIN#
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Consumer Credit Report �
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Check Driver License Status – – through Check Dl
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Terrorism/Global Clearance
Other
Other
Other
Other
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Employment Reference Verification
Last name at the the time of employment
May we contact your current employer

Yes

No
If yes above, Name of current employer
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Education/ Professional verification

Education/ Professional verification
Last Name used during schooling/course(s):
Applicant First Name:
Applicant Last Name:
Date of Birth:
MM slash DD slash YYYY

Driver's License #:
Email Address:

SIN:
Applicant Signature:
Date
MM slash DD slash YYYY

THE BELOW DISCLOSURE AND AUTHORIZATION LANGUAGE IS FOR MANDATORY USE BY ALL ACCOUNT HOLDERS

IMPORTANT DISCLOSURE
REGARDING BACKGROUND REPORTS FROM THE PSP Online Service
In connection with your application for employment with Trans Emerge (“Prospective Employer”), Prospective Employer, its employees, agents or contractors may obtain one or more reports regarding your driving, and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA).
When the application for employment is submitted in person, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer will provide you with a copy of the report upon which its decision was based and a written summary of your rights under the Fair Credit Reporting Act before taking any final adverse action. If any final adverse action is taken against you based upon your driving history or safety report, the Prospective Employer will notify you that the action has been taken and tbat the action was based in part or in whole on this report.
When the application for employment is submitted by mail, telephone, computer, or other similar means, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer must provide you within three business days of taking adverse action oral, written or electronic notification: that adverse action has been taken based in whole or in part on information obtained from FMCSA; the name, address, and thetoll free telephone number ofFMCSA; that the FMCSA did not make the decision to take tho adverse action and is unable to provide you the specific reasons why the adverse action was taken; and that you may, upon providing proper identification, request a free copy of the report and may dispute with the FMCSA the accuracy or completeness of any information or report. If you request a copy of a driver record from U1e Prospective Employer who procured the report, then, within 3 business days of receiving your request, together with proper identification, the Prospective Employer must send or provide to you a copy of your report and a summary of your rights under the Fair Credit Reporting Act.
Neither the Prospective Employer nor the FMCSA contractor snpplying the crash and safety information has the capability to correct any safety data that appears to be incorrect, You may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If you challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. Your request will be forwarded by the DataQs system to the appropriate State for adjudication.
Any crash or inspection in which you were involved will display oo your PSF report. Since the PSP report does not report, or assign, or imply fault it will include all Commercial Motor Vehicle (CMV) crashes where you were a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, all inspections, with or without violations, appear on the PSP report. State citations associated with Federal Motor Carrier Safety Regulations (FMCSR) violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report.
The Prospective Employer cannot obtain background reports from FMCSA without your authorization.
AUTHORIZATION If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below:
I authorize Trans Emerge (“Prospective Employer”) to access the FMCSAFre-Employment Screening Program (PSP) system to seek information regarding’ my commercial driving safety record and information regarding my safety inspection history. I understand that I am authorizing the release of safety performance information inoluding crash data from the previous five (5) years and inspection history from the previous three (3) years. I understand and acknowledge that this release of inforrnatlon may assist the Prospective Employer to make a determination regarding my suitability as an employee.
I further understand that uei!her the Prospective Employer uor the FMCSA contractor supplying the crash and safety information has the capability to correct nny safety data that appears to be incorrect, I understand I may challenge tho accuracy of the data by submittinga request to https://dataqs.fnicsa.dot.gov. IfI challenge crash or inspection information reported by a State, FMCSA cnnnot change or correct this data. I understand my request will be forwarded by the DataQs system to the appropriate State for adjudication.
I understand that any crash or inspection in which I was involved will display on my PSP report. Since the PSP report does not report, or assign, or imply fault, I acknowledge it will include all CMV crashes where I was a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, I understand all inspections, with or without violations, will appear on my PSP report, and State citations associated with FMCSR violations that have been adjudicated by a court of law will also appear, and remain, on my PSP report. I have read the above Disclosure Regarding Background Reports provided to me by Prospective Employer and I understand that if! sign this Disclosure and Authorization, Prospective Employer may obtain a report of my crash and inspection history. I hereby authorize Prospective Employer and its employees, authorized agents, and/or affiliates to obtain the information authorized above.
Date
MM slash DD slash YYYY

Signature
Name
First
NOTICE: Th.is funn is made ewilable to monthly account holdors by NIC OU be!talfof the U.S. Department of1JPnsµortntion, Federal Motor Carrier Safety Administratfon (FMCSA). Account hok1ers are required by feden1l la.w to oblain an Applicant’s written or alec(ronic consent prior to accessing the Applicant’s PSP report. Further, account holders arc required by :PMCSA to nae the language contained in this Disclosnro Rn
Criminal Record Verification
Surname
Surname
Given Name
First
Middle Name
First
Surname (last-name) as birth
Former Name
Place Of Birth
(City, Province/State, Country);
Date of birth
MM slash DD slash YYYY

Sex

Female

Male
Phone Number
Email Address

Current Home Address
Number
Street
Appartment
City
Province/State
Postal/Zip
Previous Address Within the Last 5 Years {attech tiddltlonal pagit If necessary)
Reason for the criminal record verification
Organization Requesting Search Trans Emerge
Contact Name: Johanna Chfford
Contact Phone Number: 905-875-6828
Information Consent
SEARCH AtTHORIZATION • I HEREBY CONSENT TO The: SEARCH OF the RCMP National Repository of Criminal Records based on the name(s), date of bitth and where used, the declared criminal record history provided by myself. I understand that this verificatlon of the Natlonal Repository of Criminal Records is not being confirmed by fingerprint comparison which is the only true means bywhkhto coofvm If a aimlnal reco,d exists in the Natlonaf Repository of Criminal Records,
POLICE INFORMATION SYSTEM(S)-1 HEREBY CONSENT TO THE SEARCH Of police lnformation system as part of e Police information Check, which will consist of a search of the following systems (check applicable):
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CPIC Investigative Data Bank
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Police information Protal
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Other
AUTHORIZATION AND WAVIER to provide a confirmation of criminal record or any police information, I certify that the Information set out by me ln this application Is true and correct to the best of my abllty. I consent to the release of the results of the criminal record checks to Trans Emerge _, located In Cambndge, Ontario, Canada I hereby release and forever discharge all members end employees of the processing Police service and the Royal Canadian Mounted Police from any and all actlons, 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
Name of Processing Police Service
to lSB Canada
Company Name
Milton on
City and Country
Signature of Applicant
Date
MM slash DD slash YYYY

Signed at
City | Province/Territory
Identification Verification
Witnessing Agents Name: Jennifer Bull
Identification Verified
Witnessing Agents Signature
Typed of photo Id Viewed
(Government Issued )& Secondary Id
Name and location of the company where lnformation will be stored In Canada: 1SB canada, Milton, ON
Information related to this criminal record check Is collected, retained and disclosed in accordance with applicable privacy legislation.*”
Declaration of Criminal Record
This form is require to be filled out and attached to your informed consent from for a criminal Record Verification
Surname(last name )
Given Name:
Date of Birth
MM slash DD slash YYYY

Information Is collected and disclosed In accordance with federal provincial and Municipal laws.
A Declaratian of Criminal Record does not constitute a Certified Criminal Record by the RCMP and may not contain all criminal record convictions.
Applicants must declare all convictions for offences under Canadian federal law.
Do not declare the following• – A conviction for which you have received a Record Suspension (formely pardon) In accordance with the Criminal Records Act.
– A conviction where you were a “young person” under the Youth Criminal Justice Act
– An Absolute or Conditional Discharge. pursuant to section 730 of the criminal Code.
– An offence for which you were not convicted
– Any provincial or municipal offence, and:
• Any charges dealt with out stde of Canada.
Note that a Certified Criminal Record can only be Issued based on the submisslon of fingerprints to the RCMP National Repository of Criminal Record.

Offense Date of Sentence Court Location

Signature of Applicant
Date
MM slash DD slash YYYY

Verified By: Cobourg Police Services
Name of Police Agency Employees
Verified By: Cobourg Police Services
Name of Police Agency Employees
Signature
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