@ POLICE CRIMINAL RECORD CHECK Q POLICE INFORMATION CHECK TO BE COMPLETED BY APPLICANT Date of Request Mailing Address (name, street, city, province, postal code) 47_/_03/_16_ Please Print Legibly under Each Heading this is your mailing label yy mm dd TaN Fea Raoe a Rae Masse Taylor Alice Mary Fala aT re 1199 Harrison Ave a — oy = Fao rr Ferd oee ae Windsor ‘Ontario NOC 34 2IAL/DR | Windsor F “Address History — please Gill ou ifresident address differs from mailing address and/or ifresided OUTSIDE of the Region in the past 5 years ‘Sireet une snd (please at baw) pita ay TFrevince [Postal Code] of yrs (SS Reason for Request (State below) ‘Reason (Volunteer, employment or other — if other, please specify) 1 Declaration of Criminal Record Attached Employment - Ontario College of Teachers Tdlentification — ove form MUST be Geveramentlorucd and inclode applicant's name, date of birth, signature and photo of applicant Tym ef lD poses! Birth Certificate Dewabe 92-387931-01 i eeccienen PaSepon ‘Pests _GB280760 ‘Contact Information | a a aa CR 519-890-3710 ‘The Police Criminal Record Cheek will include the following information sit exists on the date ofthe search: ‘© Criminal convictions from CPIC and/or local databases. Findings of Guilt under the Youth Criminal Justice Act within the applicable disclosure period. All ofthe above and the following Information as it exists on the date ofthe search: ‘The Police Information Check will inclu «Outstanding entries such as charges and warrants, judicial orders, Peace Bonds, Probation and Prohibition Orders. ‘Absolute and Conditional Discharges, within the applicable disclosure period. TOTAL NUMBER OF PAGES: GQ./ > NOT VALID UNLESS EMBOSSED WITH POLICE SEAL———— | POLICE USE ONLY | 1. RESULTS FOR RCMP NATIONAL RESPOSITORY CRIMINAL RECORDS CHECK Tonle oe ira pe EE ae aT | “ito name tepnay ocean re aan ae ee ae ey ae NEGATIVE | applicant Pesdve identicaon that «erimiaal record dots or docs notes atthe RCMP Natonsl Repontory of Criminal (wot confirmed by | Records cas ony be confirmed by FINGERPRINT comparlaos Delays do exit between a soavicnon bem rendered i curt, ris) ‘nd the deal accessible o the RCMP National Repository of Criminal Recor Not al offences we reported to the RCMP National Repostory of Criminal Records ‘Based onthe Gagerprint, samc{i, and dae of Bik vabmiied by the applicant, ts tesage ers Gat evearch fe RCMP National Repository of Criminal Records did wot ieatfy any records sociated with the wpplicant that may be disclosed in ao NEGATIVE ‘sccordance with federal laws. Delays do exist between « conviction being rendered in cour, and the detus being accessible on the (contrmed ty peat) | RCMP National Reposty of Cr Recor Natal sce ne epred whe RCMP Nana Repo of Cram ecards ‘Baoed sy ou te aume)and Ga ofr provided and he cima rexrdlaformaton declared by the apna a each oft RCMP Natal Repository of Canal Records has resulted na pone macht reglered eran eeord Putve D1 | CRaavat RECORD | ideatifeation tht a criminal record des or doesnot exist atthe RCMP Nasional Repository of Criminal Record can only be POSSIBLE MATCH | confirmed by gerpiatcomparunn. As ck, he crinlaal record infra Scered bythe applicant docs wot conse & (eotcontirmed by | Certed Criminal Record bythe RCMP. Deas do ei beteen conviction ing reed cou, md te Geta bend rat) accel nthe RCMP Naa! Rept of rina Resor Not al oes seeped he RCMP Nana Repntry of Seeanached pees | Criminal Revs This document mey not conan ll erimial record convcoas apceed with the apps ‘Based on the Gngerprintsoame(), and date of birth subaed bythe applicant, Gis massage Satie Gat esearch of Be RCMP National Repository of Criminal Records dete hat the Gngespnssubaite by te applicant were certiid a identical C1 | Cain RECORD | to fingerprints reser under criminal FPS Number. Delays do exist between & conviction beng rendered court, and the detnils (Confirmed by prints) | being accessible on the RCMP Natual Repository of Criminal Records. Not al offnoes are reported to the RCMP Naina! Seeattched page(s) | Repository of Criminal Records This doctmeat may not contain al criminal record couvictons amsocited with the applleant. ‘Based sey on the namc() and dae of th provided and Ge craiaal record Talormation declared by the applicant search ofthe RCMP National Repository of Criminal Records could NOT be completed. Positive Weatication thats crimlaal CL] comptere | record does or does ot exist requires the applcant to SUBMIT FINGERPRINTS tothe RCMP National Repository of (Criminal Record by aa authorized police service or sceredited private agerpriating company which has wot been 4o0e. Delays do exist berwece a conviction being rendered in cour, andthe dts beng acceebe onthe RCMP National Repository of (Criminal Records, Not all ofkoces ar reported to the RCMP Nasional Repoitry of Criminal Records 72. RESULTS OF INVESTIGATIVE DATABANK /LOCAL INDICES — POLICE INFORMATION CHECK ONLY "No Information was revealed tt canbe disclosed accordance with federal, RCMP polices end LEARN. Guideline or Q NEGATIVE Police Record Checks. Q ‘POSITIVE, ‘See anached page(s) fr details 2] norareticas.e | ree Poti Cio Record Ck oe nti ec of levesgve Duane nies DateofSearch MAR 17 2017 MFK497.2 NOT VALID UNLESS EMBOSSED WITH POLICE SEAL Personal information cotsined on this form is collected pursuant othe Police Services Act 41 andi collected for he purpose of procesing this police record check. ‘Questions concerning this collection shouldbe directed t: Infrmation and Privacy Co-Ordinator, PO Bax 60, Windsor, Otani, NDA 65, 519-255-6700 X45, 1. Thereby release and discharge the Windsoe Police Service and all members and employees of he tid Servic rm any and ll cons, claims and demands for damages, lots o injury howsoever wising which may berafer be sustained by mysef es result ofthe disclosure of information by the Police Service. I hereby tuthoriz the Windsor Police Service to inquire into and icloge the results of any police ecards indicating criminal convictions, coedioeal end sbyoltedncharges, ‘utstanding criminal cbarges wo me wd to conduct a local police contact search wit any Police Service in Canada 2. Teri tte inmsice prvi hy mein spi ed crete bes of my owen bel. ved scone dean fod age tot tet ad rsientsxane renerran “Tivlor Masse A IV Applicant's Signature