Form MEPS 460 PC (05) Page 1 of 1 March 2005
THE UNITED CHURCH OF CANADA
Ministry and Employment Policies and Services (Pastoral Relations)
Record of Police Record Check for Members of the
Order of Ministry in a Pastoral Charge (MEPS 460 PC)
This form must be completed by members of the Order of Ministry in pastoral charges and shared with the Ministry
and Personnel Committee.
Routing:
• Every person who signs this form must keep a copy for his/her own records.
The Ministry and Personnel Committee of Pastoral Charge,
through two of its designated members, has seen a current (within six months) original police record check
(date completed: )
Month/Day/Year
for on
Name of ministry personnel Month/Day/Year
(as required by The Manual, section 244(c) ix).
Month/Day/Year Signature: Chair of M&P Committee (or designate) Printed name: Chair of M&P Committee (or designate)
Month/Day/Year Signature: Secretary of M&P Committee Printed name: Secretary of M&P Committee
The use, retention, and disclosure of personal information collected from this form is done in compliance with privacy legislation including, but
not limited to, the Personal Information Protection and Electronic Documents Act (2000, c.5). ** THIS FORM IS NOT VALID IF ALTERED **