APPLICATION FOR CRIMINAL RECORD CHECK
Please complete this form in block letters or on a computer.
IMPORTANT : This form is not for the vulnerable sector.
Identification of applicant (block letters)
Identification of applicant based on at least two identity documents, one of which includes a photo (specify documents
For example: Driver’s license Passport Health insurance card Other (specify)
Name First name Date of birth (yyyy-mm-dd) Sex
Current address (No., street, city) Telephone
Previous addresses (last five years) (No., street, city) Postal code from (yyyy-mm) to (yyyy-mm)
Consent for criminal record check (to be signed by applicant)
I, the undersigned, hereby give my consent for the Service de police de la Ville de Gatineau to conduct a criminal record
check to determine whether I have been convicted of a criminal offence for which I have not obtained a pardon or whether I
have an active case before the criminal court.
I wish to receive the result by mail
__________________________________ ________________ In person at 590, Greber
Applicant’s signature Date (yyyy-mm-dd) In person at 830, George St. (Buckingham)
In person at 777, de la Carrière (Hull)
In person at 625, Aylmer rd. (Aylmer)
A criminal record check will not be conducted in the following cases:
• The applicant is a minor
• The required processing fees have not been paid
Payment : You can pay cash, by cheque or money order (payable to «Ville de Gatineau»). Payment is
Results : You can expect to receive an answer to your application within 15 days.
Certification of person receiving application
I hereby certify that I have checked the applicant’s identity.
Name (in block letters) Signature and employee number Date (yy-mm-dd)