Blank Criminal Report Template PDF Details

Applying for a liquor license entails navigating various procedures and submitting numerous forms, with the Criminal Report form, also known as the Personal History Summary and Consent to Criminal Record Search (Liquor Control and Licensing Form LCLB004), being a pivotal step in this rigorous process. This form serves as a comprehensive declaration of the applicant's legal and personal history, aiming to ensure that individuals seeking to own or operate a licensed establishment, liquor manufacturer, or liquor agency meet the legal and ethical standards set by the authorities. Applicants are required to provide detailed information about their residence, employment, and any associations with liquor licenses or manufacturers. Furthermore, it mandates consent for a criminal record search by the Royal Canadian Mounted Police, making it a crucial document for assessing an applicant’s eligibility. The form consists of clear instructions, including the necessity to submit it along with other required documents to the Liquor Control and Licensing Branch Head Office, and specifies that it can be filled out on a computer or by hand, provided it is legible and in dark ink. Questions range from personal information, residence details, involvement with liquor licenses in the past, to any criminal or drug/alcohol-related offences, emphasizing the applicants' responsibility to provide truthful and complete information. Moreover, it outlines the consequences of failing to disclose material facts or providing misleading information, underscoring the legal responsibilities that come with the application process.

QuestionAnswer
Form NameBlank Criminal Report Template
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namescriminal file template, blank criminal case file template, criminal profile sheet template, criminal record template

Form Preview Example

Personal History Summary and

Consent to Criminal Record Search

Liquor Control and Licensing Form LCLB004

INSTRUCTIONS:

After completing this consent form, please submit it, along with your application and other required documents, to the Liquor Control and Licensing Branch Head Office. You may complete this form at your computer, then print. If you are completing this form by hand, please print clearly using dark ink.

•If you have any questions about completing this form, call the branch toll-free at: 1-866-209-2111.

•LCLB forms and supporting materials referred to in this document can be found at: www.pssg.gov.bc.ca/lclb

Location of (proposed) licensed establishment, liquor manufacturer or liquor agency:

StreetCityProvince Postal Code

Legal Entity Name:

 

Licence or Job #:

 

 

 

 

 

 

 

 

(i.e. sole proprietor, partnership, private corporation, society)

(not applicable if application is not already in progress)

 

 

 

 

 

Full Name:

 

Gender (Please check): M

 

(last / first / middle)

 

F

BIRTHDATE:

(year / month / day)

Birthplace:

Last name at birth:

Other last names used:

Residence Address:

 

 

 

Have you used any other names? (Please check): Yes

No

 

 

 

If yes, please provide name details below:

 

 

 

 

 

 

First and middle names at birth:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other first and middle names used:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street

City

Province / Country

Postal Code

Business Tel with area code:

Personal Tel with area code:

Business Fax with area code:

Business e-mail:

1.Do you reside in B.C. for the majority of the year (i.e., more than 6 months)? Yes If NO, please provide details of where you reside for the remainder of the year:

No

2.

Are you a permanent resident who has resided in Canada for less than the past five years? Yes

No

 

 

If yes, attach a copy of your "Record of Landing" (Form IMM1000, Permanent Resident Card or equivalent documentation), as

 

provided by Citizenship and Immigration Canada when you entered the country, and a statutory declaration signed by a lawyer,

 

Notary Public or Commissioner for Taking Affidavits stating that you have not been charged with, discharged, or convicted of a

 

criminal or drug/alcohol-related offence; or providing details of any past charges, discharges, convictions or sentences outside of

 

Canada. (For further information and to review a sample statutory declaration, refer to this LCLB web page:

 

 

http://www.pssg.gov.bc.ca/lclb/LLinBC/criminal_record_search.htm

 

 

3.

Are you either living outside of Canada or a refugee who has been in Canada for less than five years?

Yes

No

If yes, please attach a statutory declaration signed by a lawyer, Notary Public or Commissioner for Taking Affidavits stating that you have not been charged with, discharged or convicted of a criminal or drug/alcohol-related offence; or providing details of any past charges, discharges, convictions or sentences outside of Canada. To review a sample statutory declaration, refer to this LCLB web page: http://www.pssg.gov.bc.ca/lclb/LLinBC/criminal_record_search.htm

4. Have you ever held, or do you presently hold, an interest in a liquor licence?

Yes

No

If yes, provide details of licence(s) or application(s): date, location, name of establishment, licence type, current status, etc.):

(Attach a separate sheet to this application if additional space is required.)

5. Do you currently hold a Rural Agency Store appointment from the Liquor Distribution Branch (LDB)? Yes

No

 

 

 

 

LCLB004 (Last updated 15 May 2012)

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Personal History Summary and Consent to Criminal Record Search

Note: If you are submitting an application for an agent's or manufacturer's licence, please select “N/A” for questions 6 and 7. All other applicants must answer “Yes” or “No” for questions 6 and 7.

6.Have you agreed with anyone to sell the liquor of a manufacturer to the exclusion of another liquor manufacturer?

Yes

No

N/A

If yes, provide details:

 

 

 

 

 

 

 

 

7.Do you or your immediate family members have any association with, or financial interest in, a liquor manufacturer, a liquor

importer, or the agent of a liquor manufacturer/importer? Yes

No

N/A

If yes, provide details:

 

 

 

 

 

 

 

 

8.Have you entered into a Shareholder Agreement, Profit Sharing Agreement or other similar agreement with anyone not named in the

licence application? Yes

No

If yes, provide details (including percentage of interest shared with others):

 

 

 

 

 

 

9.Have you received any alcohol-related driving infractions in the past five (5) years in Canada or under the laws of any other country

or state? Yes

No

If yes, provide one of the following:

(a)For driving infractions in Canada, provide a copy of your driver's abstract (driving record) for the past five (5) years. For information on how to acquire a copy of your BC driver's abstract, visit www.icbc.com/driver-licensing/driving-record or call in Victoria 250-978-8300 or elsewhere in BC 1-800-950-1498. For information on how to acquire a copy of your driver's abstract for any other Canadian jurisdiction, contact that jurisdiction directly.

(b)For driving infractions outside of Canada, provide a statutory declaration signed by a lawyer, Notary Public or Commissioner for Taking Affidavits that details the infraction, the date and the sentence or fine. (if not required on Question 3) For further information and to view a sample statutory declaration, refer to this LCLB web page: http://www.pssg.gov.bc.ca/lclb/

LLinBC/criminal_record_search.htm

10.Have you ever been charged with, discharged or convicted of, a criminal or drug/alcohol related offence under the laws of any

country or the laws or bylaws of any provincial, state or local government? Yes

No

If yes, provide the following:

(i)a statutory declaration signed by a lawyer, Notary Public or Commissioner for Taking Affidavits providing details (i.e. date, disposition and sentence or fine, if applicable) of any charges, discharges, convictions or sentences inside or outside of Canada. For further information and to view a sample statutory declaration, refer to this LCLB web page: http://www.pssg.gov.bc.ca/ lclb/LLinBC/criminal_record_search.htm

(ii)a copy of your driver's abstract (driving record) for the past five (5) years. For information on how to acquire a copy of your BC driver's abstract please visit www.icbc.com/driver-licensing/driving-record or call in Victoria 250-978-8300 or elsewhere in BC 1-800-950-1498. For information on how to acquire a copy of your driver's abstract for any other Canadian jurisdiction, please contact that jurisdiction directly.

If you have been issued a driver's licence outside Canada in the past five (5) years, provide a statutory declaration signed by a lawyer, Notary Public, or Commissioner for Taking Affidavits that states you have or have not received any alcohol-related driving infractions in the past five years. If you have received any alcohol-related infractions, provide details of the infraction, the date, sentence or fine if applicable.

11.Attach a legible (colour preferred) photocopy of your driver's licence, passport or any other government-issued photo ID.

12.Attach completed "Consent for Disclosure of Criminal Record Information" form (RCMP GRC3584)

DECLARATION AND AUTHORIZATION

My signature below indicates I understand and acknowledge that :

1.All the information given is true and complete to the best of my knowledge. Section 15(2) of the Liquor Control and Licensing Act states "A person applying for the issue, renewal, transfer or amendment of a licence who fails to disclose a material fact required by the form of application or makes a false or misleading statement in the form of application, commits an offence."

2.If the Liquor Control and Licensing Branch grants a licence as a result of this application, it will be granted only to the person(s) named in the application, or to a private corporation containing the principal shareholders and executive officers named in the application or to a public corporation or society containing the executive officers named in the application.

3.My signature authorizes the Royal Canadian Mounted Police to inquire into, and determine whether or not I may have a criminal record and report their findings to the Liquor Control and Licensing Branch. If necessary, I will provide my fingerprints to verify whether or not I may have a criminal record.

4.I understand I must provide a copy of my driving record for the past five (5) years if requested by the general manager.

Signature of Individual:

 

Date signed:

 

 

 

 

 

 

 

Freedom of Information and Protection of Privacy Act - the information for a liquor licence is collected under the authority of the Liquor Control and Licensing Act (RSBC 1996, c.267, s.15). The information is collected for the purpose of determining your eligibility for a liquor licence. Information may also be used by the Liquor Distribution Branch to determine your eligibility to purchase liquor. If you have any questions about the collection, use or disclosure of this information, please contact the Liquor Control and licensing Branch.

LCLB004

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Personal History Summary and Consent to Criminal Record Search

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Step 2: Now, you can alter your blank criminal profile template. This multifunctional toolbar lets you insert, erase, change, highlight, as well as do many other commands to the content and fields inside the form.

You should provide the next information if you need to fill in the template:

example of empty fields in criminal report template

Write down the details in Are you a permanent resident who, If yes attach a copy of your, Are you either living outside of, If yes please attach a statutory, Have you ever held or do you, Yes No, If yes provide details of licences, Do you currently hold a Rural, Yes No, Attach a separate sheet to this, and LCLB Last updated May Personal.

Entering details in criminal report template step 2

Note down the vital information while you're within the Have you agreed with anyone to, If yes provide details, Do you or your immediate family, Yes No NA, If yes provide details, Have you entered into a, If yes provide details including, Yes No, Have you received any, or state Yes No a For driving, If yes provide one of the following, information on how to acquire a, and b For driving infractions outside part.

Filling in criminal report template step 3

Please make sure to place the rights and responsibilities of the parties within the Have you ever been charged with, If yes provide the following, Yes No, disposition and sentence or fine, ii a copy of your drivers abstract, Attach a legible colour preferred, DECLARATION AND AUTHORIZATION My, and All the information given is true section.

Finishing criminal report template stage 4

End by analyzing all of these sections and completing the relevant data: My signature authorizes the Royal, Signature of Individual, Date signed, Freedom of Information and, and LCLB Personal History Summary and.

Filling in criminal report template stage 5

Step 3: After you've clicked the Done button, your document will be readily available export to any type of gadget or email you identify.

Step 4: To avoid any specific hassles as time goes on, try to prepare minimally a couple of copies of the document.

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