ST. JOHN CANADA INSTRUCTIONS
(Letterhead)
Sample
AUTHORIZATION FOR POLICE RECORDS CHECK
This request is for a volunteer position with the St. John Ambulance Brigade.
I, the undersigned authorize the local police to release to St. John Ambulance, full
disclosure of police information relating to criminal charges and convictions recorded in
my name for which a pardon has not been granted.
Please Print
I hereby consent to the full
disclosure of the following classes of information provided by this process: |
A. Criminal Record (Adult) |
B. Criminal Record (Young Person).* |
C. Records of "Not Guilty by
Reason of Mental Competence". |
D. Pending charges and/or complaints
under Federal Statutes |
E. Pending charges and/or complaints
under the "Child & Family Services Act". |
F. Record(s) of convictions for
offences under the "Child & Family Services Act". |
G. Record(s) of traffic
accidents/convictions |
*Pursuant to section 44(1) of the Young Offenders
Act, a young offender record can be made available to the young person to which the record
relates and for the purpose of granting a security clearance in accordance with section
44(1)(i) Young Offenders Act. |
I hereby release St.
John Ambulance, the local police and any other police authorities, from any liability for
such disclosure. I understand that this check may involve fingerprinting for the purpose
of verification of my identity. I also consent to this procedure should it be required. |
Note: The information provided does
not necessarily mean the applicant will be disqualified from the position by St. John
Ambulance. |
Signed this __________ day of
_____________________ 19 _____ |
_____________________________________________
Signature of Applicant
_____________________________________________
Signature - St. John Ambulance Witness |