Consent Release Form Instructions

Form Name: Criminal Record Check Consent

This form is needed to complete a search related to your background check. Please complete
the attached form entirely and return to SterlingBackcheck.

You must include the attached Cover Sheet when returning the completed form.

Choose one option below:

1. Upload Signed Form to SterlingBackcheck

• If you are still in the process of filling out your information, upload a scanned copy or
photo image of the signed form along with the attached Cover Sheet on the
“Required Forms” step by clicking the “Upload” button
• If you have already completed all other steps and submitted your data, you will
receive a separate email with a link to the Activity Center where you will be able to
upload the signed form

2. Email Signed Form to SterlingBackcheck

• Email the signed form along with the attached Cover Sheet to:
SWIntl.AdditionalDocs@sterlingbackcheck.com

3. Fax Signed Form to SterlingBackcheck

• Fax the signed form along with the attached Cover Sheet to:
1 800-943-2459 (US and Canada toll free)
+1 646-536-5286 (toll)

4. Mail Signed Form to SterlingBackcheck

• Mail the original signed form along with the attached Cover Sheet to:

SterlingBackcheck
6111 Oak Tree Blvd, 4th Floor
Independence, OH 44131
United States
ATTN: Criminal Department

Support: +1-888-889-5248 (US and Canada toll free) sterlingbackcheck.com

+1-646-829-3382 (Toll)
 USE THIS COVER SHEET
(Must accompany all signed forms)

----- URGENT -----

ATTENTION: AWAITING INFO TEAM

FAX: 1 800-943-2459 (US and Canada toll free)

+1 646-536-5286 (toll)

EMAIL: SWIntl.AdditionalDocs@sterlingbackcheck.com

CLIENT: VIPKID HK Ltd./24898

APPLICANT ID: 2481244

CONSENT FORM: Criminal Record Check Consent

Support: +1-888-889-5248 (US and Canada toll free) sterlingbackcheck.com

+1-646-829-3382 (Toll)
Canada – Criminal Record Check
The Criminal Search in Canada requires proof of identity be provided.

Note to candidate: The form below requires both your signature and the signature of a representative of the
Company. Please work closely with your contact at the Company to correctly process the
signatures required.

First name: Ciaran

Middle name: Seamus
Last name: Farrell
Current address: Cra. 91 #65C 95
Address line 1

Address line 2

Medellin Antioquia
City/town State/province/region

Canada
Zip/postal code Country

Date of birth: 1995 11 28

Year Month Day

Maiden/Alias Names
1.
First Name Middle Name Last Name

2.
First Name Middle Name Last Name

3.
First Name Middle Name Last Name

Position applied for: Teacher

Gender: ✔ Male Female

Place of birth: Saint Germain en Laye Yvelinnes France

City/town State/province/region Country

Proof of ID

Two (2) pieces of legible identification are required:

1. The first of which must be government-issued and include the applicant’s name, date of birth, signature
and photo (e.g. Driver’s License, Passport, Citizenship Card, Permanent Resident Card, Certificate of Indian
Status).
2. The second should be government-issued; however at minimum it must include the full name of the
candidate.

Canada_Criminal -1
Canada – Criminal Record Check
Consent for Disclosure of Personal Information
Name Based Canadian Criminal Record Check
To ensure accuracy, you must PRINT in clear CAPITAL letters and complete this form in its entirety.

As part of the background check, the Company will ask SterlingBackcheck Canada Corp. and its parent, affiliates and
Supplemental Privacy Notice

subsidiaries (“SterlingBackcheck”, “we” or “us”) to conduct Canadian Criminal Record Check (CRC). This is a search of the
Royal Canadian Mounted Police (RCMP) National Repository of Criminal Records, conducted by a Canadian police service
on our behalf through the Identification Data Bank of the Canadian Police Information Centre (CPIC) using your name(s),
date of birth and declared criminal record. The result will indicate whether a criminal record exists that may match your
personal information, and whether your declared criminal record is a complete and accurate match to the record on file.
In some cases, the search may be inconclusive. We will not receive details of your criminal record other than those you
provide. Only the submission of your fingerprints to the RCMP can result in the release of a Certified Criminal Record and
resolve inconclusive or disputed results.

What should you disclose? All criminal offences (offences under the Criminal Code of Canada, the Controlled Drugs and
Substances Act or other federal laws that designate criminal offences) for which you have been convicted as an adult and
have not received a pardon or record suspension. What should you NOT disclose? Offences for which you have not been
convicted, such as pending or dismissed charges, acquittals or absolute or conditional discharges; convictions where you
were considered a “young person” under the Youth Criminal Justice Act or its predecessors; provincial or municipal
offences such as speeding or parking tickets; charges dealt with outside of Canada; and convictions for which you have
received a pardon or record suspension.
Declaration of Offenses

Have you been convicted of a criminal offence for which a pardon or record suspension has not been granted?
Yes ✔ No

If you have answered Yes to the question above, please provide details on those criminal convictions (attach additional
pages if required):
Offence Date (yyyy/mm/dd) Location Penalty
Statement of Understanding

By signing below, I acknowledge that I have read the supplementary privacy notice above and I consent to the collection,
and Consent

use and disclosure of my personal information as described in it.

Candidate signature (authorizing name based CRC) Date (YYYY.MMM.DD) ▼

X 2020.06.24

Canada_Criminal -2
Canada – Criminal Record Check
ID Verification
I have examined the identification of
Print Name of Representative Print Name of Candidate

and I am satisfied that the candidate and the person depicted in the photo identification are one and the same.

Authorized Company Representative’s signature Date (YYYY.MMM.DD) ▼

(witnessing candidate’s signature & confirming ID check)

Canada_Criminal -3