Dnd 2576 E Form – Fill Out and Use This PDF

Consent to Disclosure of Criminal Information

Identification of person providing consent:

Surname		Given name(s)	Second			Third
Maiden	Place of birth		Gender		Male	Date of birth (yy-mm-dd)
					Female
	Home			Work
Telephone numbers:
Current address and Previous addresses, if any, within the last 5 years (including applicable dates of residence)

Reason for consent:

I am applying for a job which requires a basic police check.

I am an applicant for a paid or volunteer position with a person or organization responsible for the well being of one more children or vulnerable persons.

Other:

Description of Position / Job:

Name of Organization / Person:

Signature of organization representative

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Consent:

For all applications:

I consent to a search of police records, criminal convictions, local indices and other means for significant incidents and/or offences from which a pardon has not been granted and/or outstanding criminal charges of which the Military Police are aware, through consultation with the Canadian Police Information Centre (CPIC) and the Military Police National Records Centre (MPNRC).

The particulars of the subject of this waiver have been verified by photo identification (attach photocopy). If required, fingerprints will be provided for comparison to verify the existence/non-existence of a Criminal Record.

Signature

Date (yy-mm-dd)

For all positions of authority or trust with children or vulnerable persons:

I consent to a search being made in the automated criminal records retrieval system maintained by the Royal Canadian Mounted Police to find out if I have been convicted of, and been granted a pardon for, any of the sexual offences that are listed in the schedule to the Criminal Records Act.

I understand that, as a result of giving this consent, if I am suspected of being the person named in a criminal record for one of the sexual offences listed in the schedule to the Criminal Records Act in respect of which a pardon was granted or issued, that record may be provided by the Commissioner of the Royal Canadian Mounted Police to the Minister of Public Safety for Canada, who may then disclose all or part of the information contained in that record to the Military Police.

The Military Police will then disclose that information to me. If I further consent in writing to disclosure of that information to the person or organization referred to above that requested the verification, that information will be disclosed to that person or organization.

Signature

Date (yy-mm-dd)

I hereby release and forever discharge Her Majesty the Queen, the Military Police, and all members and employees of the Canadian Forces from any and all actions, claims and demands for damages, loss, or injury however arising which may hereafter be sustained by myself as a result of the disclosure of information by the Military Police to me and/or the above named organization. I acknowledge that information so disclosed may be confirmed only by comparison of the fingerprints on file to which the information relates and my fingerprints.

Signature

Date (yy-mm-dd)

Our Records Check:

Failed to reveal any record relating to the above subject. Positive determination that no record exists in another name for this subject can only be made through fingerprint analysis. No fingerprint comparison was conducted for this subject.

There may or may not be a criminal record in existence. Information can only be confirmed by fingerprint comparison.

Note: The existence nor the particulars of any record regarding a young offender will be disclosed

STATEMENT OF CONFIDENTIALITY:

This record and the information contained therein are being provided in confidence and shall not be disclosed to any person other than the person and/or agency indicated.

DND 2576-E (11-2011)

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