Informed Consent FormCRIMINAL RECORD VERIFICATION
A. Personal Information
Surname (last name): El allioui Given name(s): Mehdi
Surname (last name) at birth: El allioui Former name(s):
Place of birth (City, Province/State, Country): Casablanca, Casablanca [Dar el Beïda], MOROCCO
Date of birth (YYYY-MM-DD): 1993-07-31 Sex (check one) Female Male
Current Home Address
304-4600 AV COLOMB BROSSARD Quebec J4Z 0J6
Number Street Apartment City Province/Territory/State Postal/ZIP code
Previous Address(es)Within the Last 5 Years (attach additional page if necessary)
B. Reason for the Criminal Record Verification
Reason for Request (example Employment - Employer - Job Title): Employment - UPS QUEBEC - Employment
Organization Requesting Search: UPS QUEBEC
Contact Name: MICHELLE SKABAR Contact Phone Number: 9056766361
C. Informed Consent
SEARCHAUTHORIZATION-I HEREBY CONSENT TO THE SEARCH OF the RCMP National Repository of Criminal Records based on the
name(s), date of birth and where used, the declared criminal record history provided by myself. I understand that this verification of the
National Repository of Criminal Records is not being confirmed by fingerprint comparison which is the only true means by which to confirm
if a criminal record exists in the National Repository of Criminal Records.
POLICE INFORMATION SYSTEM(S) - I HEREBY CONSENT TO THE SEARCH OF police information systems, as part of a Police Information
Check, which will consist of a search of the following systems (checkapplicable):
CPIC Investigative Data Bank Police Information Portal (PIP)
OTHER:
AUTHORIZATION AND WAIVER to provide a confirmation of criminal record or any police information.
I certify that the information set out bymein this application is true and correct to the best ofmyability. I consent to the release of the
results of the criminal record checks
UPS QUEBEC LACHINE, CANADA
to , located in
Company Name City and Country
I hereby release and forever discharge all members and employees of the processing Police Service and the Royal Canadian Mounted
Police from any and all actions, claims and demands for damages, loss or injury howsoever arising which may hereafter be sustained by
myself as a result of the disclosure of information
by the Brockville Police Service / Cobourg to First Advantage Canada Inc. Toronto, ON, Canada
Police Service Company Name City and Country
Name of Processing Police Service
Signature of Applicant Date Signed at
Year Month Day
BROSSARD Quebec
2023 08 28
City Province/Territory
D. Identification Verification Electronic Electronic Identity Verification/Facial Recognition
Witnessing Agent's Name: Kevin Ricketts Identification Verified: YES
Witnessing Agent's Signature Type of Photo ID Viewed
(Government Issued) & Secondary ID
Name and location of the company where information will be stored in Canada: First Advantage Canada, Inc. Toronto, ON
**Information related to this criminal record check is collected, retained and disclosed in accordance with applicable privacy legislation.**
Form Version Date 2017-05-16
CRIMINAL RECORD VERIFICATION
Declaration of Criminal Record Form
Declaration of Criminal Record
This form is required to be filled out and attached to your Informed Consent Form for a Criminal Record Verification.
Surname(lastname) El allioui Givenname(s) Mehdi DateofBirth 1993-07-31
YYYY-MM-DD
Informationis collected and disclosed in accordance with federal,provincial and municipallaws.
A Declaration of CriminalRecorddoes not constitute a CertifiedCriminal Recordby the RCMPand may notcontain all criminal record
convictions.
Applicants must declare all convictions for offences under Canadian federal law. Do not declare the following:
-A conviction for which you have received a Record Suspension (formerly pardon) in accordance with the Criminal Records Act;
-A conviction where you were a "young person" under the Youth Criminal Justice Act;
-An Absolute or Conditional Discharge, pursuant to section 730 of the Criminal Code;
-An offence for which you were not convicted;
-Any provincial or municipal offence, and;
-Any charges dealt with outside of Canada.
Note that a Certified Criminal Record can only be issued based on the submission of fingerprints to the RCMP National
RepositoryofCriminalRecord.
Offence Date of Sentence Court Court Location
2023-08-28
Signature of Applicant Date (YYYY-MM-DD)
Verified By:
Name of Police Officer
Signature of Police Officer
