Aspen View Regional Division No.19

GBAA – E 2

CRIMINAL RECORD DISCLOSURE REQUEST

A request for disclosure of criminal record is required for all new and/or potential Aspen View Schools employees or volunteers.

Agency: Aspen View Regional Division No.19

1. Surname: _________________________________________________

2. Given Names: _________________________________________________

3. Sex: _______________

Maiden Name: __________________________ Birthdate: _________________

Phone Number: _________________________________

Address: ____________________________________________________________

___________________________________________________________

e-mail address: _____________________________________________________

I hereby authorize the RCMP to conduct a check to determine if I have a criminal record. The criminal record or the certification that no record exists will be forwarded back to me by the police and not to the Division Office. It will be my responsibility to provide this documentation to the Aspen View Regional Division No. 19 office in a timely manner, in order that the Aspen View Schools may proceed further with my application.

I understand that the existence of a criminal or driving record may be grounds for rejection of this application.

Signed: ________________________________

Witness: ________________________________

Date: ________________________________