Blank Criminal Report Template – Fill Out and Use This PDF

Blank Criminal Report Template PDF Details

The LCLB004 Personal History Summary is a two-page consent form issued by the Liquor Control and Licensing Branch (LCLB) in British Columbia, Canada. It authorizes the Royal Canadian Mounted Police to conduct a criminal record search on the applicant. The LCLB reviews the results to assess whether an applicant meets the legal and ethical standards required for a liquor license or permit.

Who Needs to Complete This Form

This document is required for several types of applicants. You must complete it if you are:

• Applying for a new liquor primary or food primary license in British Columbia
• Adding a new owner, director, shareholder, or partner to an existing license
• Seeking a liquor manufacturer permit or agency authorization
• Applying for a Rural Licensee Agent designation
• Any person with a financial interest in a licensed establishment

Key Information Required on the Form

The form requires a detailed personal and professional history. Applicants must provide:

• Full legal name, date of birth, and contact details
• Proof of permanent residency or citizenship status
• Residential address history for the past ten years
• Complete employment history, including any self-employment
• Details of all current and past liquor license involvements
• Information on any agreements with existing license holders
• Disclosure of all criminal charges, convictions, and drug-related offenses
• Driving infractions and a copy of your driving abstract if applicable

Consequences of Inaccurate or Incomplete Information

Accuracy is a legal requirement. Providing false or incomplete information on this form may lead to immediate rejection of your application. It can also result in cancellation of any existing license. In some cases it may lead to further legal consequences under BC liquor regulations. The LCLB takes disclosure obligations seriously.

Submission Instructions

Complete the form on a computer or write it by hand in dark ink. All handwritten text must be legible. Print the completed form and sign the Declaration and Authorization section. Submit it along with your main license application to the LCLB Head Office. Attach a legible, colour-preferred photo ID and any required court documents or driving records.

For related forms, you may also need a liquor license application form or a personal history form. If a background check consent form is needed, see our background check consent form.