CONSENT TO DISCLOSURE

Please print.
SURNAME GIVEN NAMES MIDDLE NAME

MAIDEN NAME (if applicable) OTHER NAMES USED (either past or present, E-MAIL
including aliases or nicknames)

D YYYY MM DD SEX SIN (optional) PLACE OF BIRTH PHONE

O
B
Address
Number Street Apt./unit City Province Postal code

Provide previous address(es) if you have not resided at the above address for more than five years (use additional paper if
necessary)
Number Street Apt./unit City Province Postal code

Have you ever been convicted of a criminal offence for which a record suspension (pardon) has not been issued in Canada? Yes No
If yes, please complete attached form entitled DECLARATION OF A CRIMINAL RECORD

I hereby give authorization to Garda Background Screening Solutions (Garda), acting on behalf of Home Trust Company to obtain the
following information:
References from any professional and personal associates I have or will provide, including information on my attendance, technical skills,
interpersonal relations and any other pertinent information related to my candidacy;
Details regarding any academic training, verification of any diplomas or degrees received; and verification of any professional
accreditations;
I authorize a search by a Canadian police service of the identification data bank via the Canadian Police Information Centre (CPIC) for the
following records:
I. Records of criminal convictions for which a record suspension (pardon) has not been granted in accordance with the Criminal
Records Act;
And I understand that the police service will provide a response to Garda based on their search of these records. The response provided may
only be verified by providing fingerprints for comparison with the records held by the National Criminal Repository. In the event that I have lived
in a country other than Canada, I further authorize an equivalent criminal record search in any such country that I have resided. This includes
release of any records relating to my criminal history from any organization, police court, judicial authority or tribunal.

RELEASE AND DISCHARGE

Purpose of Consent: Background Screening for Home Trust Company.

I understand that the information obtained as a result of this authorization will be held in the strictest of confidentiality by Garda and/or Home
Trust Company will be maintained in accordance with their respective Privacy Policies. The information obtained will only be used in
accordance with and to satisfy the scope for which this authorization has been signed. I release, waive and forever discharge anyone who
provides information in relation to this release, from any and all liability for the disclosure of information to Garda or Home Trust Company.

I acknowledge that records and/or information located and/or disclosed by the police service may or may not pertain to me. Positive
identification can only be confirmed through the comparison of fingerprints which must be submitted by me.
I certify that the information set out by me in this authorization is correct. Before signing this authorization, I have fully informed myself of its
content and meaning and have a full understanding of it.
Applicant Signature: _________________________________________ Date: ____________________

Witness:
An Applicant must provide two (2) pieces of valid identification, one of which must be government-issued and include the Applicants name,
date of birth, signature and photo of the Applicant. Please see Identification page for additional information.
Witness statement I have viewed the enclosed identification and I certify and have verified the identity of the Applicant by comparing the
signature on the government-issued identification to the signature on this consent form.
Signature of witness: ________________________Name in print letters: _______________________________________________
Address of witness:___________________________________________________________________________________________
NUMBER STREET MUNICIPALITY POSTAL CODE

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PROFESSIONAL REFERENCES
(You must supply at least 3 references who may be contacted, do not provide references who you do not wish Garda to contact.
Please provide a supervisor or manager wherever possible. Family members and social acquaintances may not serve as references.)
How long known?: Relationship to candidate:

Name of contact Company Title & Position Telephone E-mail

How long known?: Relationship to candidate:

Name of contact Company Title & Position Telephone E-mail

How long known?: Relationship to candidate:

Name of contact Company Title & Position Telephone E-mail

EDUCATION (Please provide the name of the educational institution attended, name of the degree or diploma earned, start date and
completion date.)
Name of Location (city & Type of degree/
Start date Completion date Graduated?
institution province/state) diploma received
Yes No
Yes No
Yes No

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 IDENTITY VERIFICATION

All applicants for a criminal record check must provide government-issued identification prior to undergoing a name-based criminal record
check. Legible copies of the identification must be included with the authorization form.

An applicant must provide copies of two (2) pieces of valid identification, one of which must be government-issued and include the
applicants name, date of birth, signature and photo of the applicant. Copies of the identification documents must be certified by a witness
who will confirm that the applicant signing the informed consent is the individual on the government-issued identification. The witness
verifying the identity of the applicant must compare the signature on the government-issued identification to the signature on the Informed
Consent form.

Primary/Photo Identification Standards Secondary Identification Standards

The primary identification must be from list: The secondary identification can also be from the above list,
Drivers Licence (issued by Canadian province or or any one of the following:
territory) or Nexus Card Birth Certificate
Foreign Drivers Licence Baptismal Certificate
Photo Health Card Hunting Licence
Canadian Passport Fishing Licence
Foreign Passport Outdoors Card
Canadian Citizenship Card Hospital Card
Permanent Resident (PR) Card Immigration Papers
Certificate of Indian Status Canadian Blood Donor Card (only if date of birth
Firearms Acquisition Certificate (FAC) indicated)
Federal, Provincial or Municipal Identification Card Student Identity Card (as long as name is shown)
Military Family Identification Cad (MFID)

Witness Requirements:

The witness must personally view the identification provided and ensure that it matches the person signing this form. The witness may be
contacted as part of an audit of this process to verify that this occurred.

The witness must be one of the following:

An employee of the company for which this background screening is being completed or;

A duly authorized and licensed notary public or;

An independent arms length witness. This is defined as a person who is not related by marriage or blood to the candidate or
otherwise in an intimate relationship. The witness must be at least 18 years of age and have known the candidate personally for a
minimum of 2 years. To know an applicant personally means that the witness is able to confirm aspects of the applicant's personal
attributes such as name, approximate age, place of birth, physical description and some personal history.

Note to Applicant: You may make a request for access to your personal information, a request for correction or any other request for
information by sending a written request to Garda (Garda Background Screening Solutions 1303 William Street, Suite 200, Montral, QC, H3C
1R4 to the attention of Privacy Officer. Garda will answer your request for access, correction or information within thirty (30) days following its
reception.

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