Sterling logo.jpg Canada: Consent to Disclosure of Personal Information Client Information (Please type or print clearly, illegible information cannot be processed) *Required Fields * NAME OF COMPANY United Synagogue of Conservative Judaism (USCJ) MAILING ADDRESS STREET / PO BOX / RR# CITY/PROVINCE/STATE POSTAL CODE / ZIP CODE 820 Second Avenue, 10 th Floor New York, NY 10017-4504 Applicant Information For the purpose of assessing my suitability for employment, I authorize the above named Company through its agent, Sterling InfoSystems, Inc. ( Sterling ) and its affiliate ISB Corporate Services to obtain information regarding: 1. Criminal records which relate to me; Police files, from any law enforcement agency, Canadian or otherwise, which relate to me; 2. Employment or Personal reference verification and/or Education, professional license verification which relate to me; 3. Consumer credit report which relates to me, and/or; 4. Driver s abstract/record from the province of. Please check appropriate box(es) below: Criminal Record Search Credit Report / Financial Inquiry... Driver s Record / Abstract Employment Verification... Professional Reference Verification. Education Verification Personal Reference Verification Professional License Check... Vulnerable Sector Check Commercial Vehicle Operator's Registration (CVOR) Consent: I also hereby consent that any information that is obtained by the foregoing search processes may be released to the above named Company and any of its agents, and the party requiring the security through its Agent, at the discretion of the processing Canadian Police Department. Furthermore, I understand and consent to my information being transferred outside of Canada for the purposes of conducting background checks and storing of the results of the checks by Sterling, the Company or its parent or affiliates. If I am hired by the Company, I also consent to the use of the information obtained in the background checks in the administration of the employment relationship. Certification and Release: I certify that the information set out by me in this application is true and correct. I hereby release the above named Company and its agents, and forever discharge all members and employees of the processing Police Department and its agents 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 processing Police Department to the organizations listed herein. I also release each corporation, Company, institution, person, law enforcement agency, criminal, civil and federal court, employer and former employer, who or which provides information to the company or its authorized agent. Information is Collected and Disclosed according to the Personal Information Protection Act (PIPA), or the Personal Information Protection & Electronic Documents Act (PIPEDA), or the Municipal Freedom of Information & Protection of Privacy Act (MFIPPA), whichever is applicable. * Name: LAST FIRST MIDDLE MAIDEN (if applicable) * Address: STREET / PO BOX / RR # CITY / PROVINCE / STATE POSTAL CODE / ZIP CODE Telephone #: * Gender: MALE or FEMALE (please circle) AREA CODE + NUMBER Driver s License #: * Date of Birth: Place of Birth : S.I.N. YEAR MONTH DAY CITY / PROVINCE / COUNTRY OPTIONAL FOR CREDIT REPORT By signing this consent and release, I acknowledge full understanding of its content and meaning. *Signature of applicant: *Date: Witnessed by Client: 2 pieces of Gov t issued ID (1 must be picture) verified : Driver s License Birth Certificate Health Care Card Passport Other: GOV T ISSUED ONLY * Signature : Print: Date: VULNERABLE SECTOR SEARCH: To be completed if the applicant is applying for a position with a person or organization responsible for the well being of one or more children or vulnerable persons, if the position is one of authority or trust, or one where limited supervision exists, relative to those vulnerable individuals, and the applicant wishes to consent to a search being made in criminal conviction records to determine if the applicant has been convicted of a sexual offence listed in the schedule to the Criminal Records Act and has been pardoned. I ALSO CONSENT TO A SEARCH BEING MADE THROUGH THE CANADIAN POLICE INFORMATION CENTRE TO DETERMINE IF I HAVE BEEN CONVICTED OF, AND BEEN GRANTED A PARDON FOR ANY OF THE SEXUAL OFFENCES THAT ARE LISTED IN THE SCHEDULE TO THE CRIMINAL RECORDS ACT, I UNDERSTAND THAT, AS A RESULT OF GIVING THIS CONSENT, IF I AM SUSPECTED OF BEING THE PERSON NAMED IN A CRIMINAL RECORD FOR ONE OF THE SEXUAL OFFENCES LISTED IN THE ABOVE-NAMED SCHEDULED IN RESPECT OF WHICH A PARDON WAS GRANTED OR ISSUED, THE SAID RECORD MAY BE PROVIDED BY THE COMMISSIONER OF THE RCMP TO THE SOLICITOR-GENERAL OF CANADA, WHO MAY THEN DISCLOSE ALL OR PART OF THE INFORMATION CONTAINED IN THAT RECORD TO THE POLICE SERVICE. THE POLICE SERVICE WILL THEN DISCLOSE THAT INFORMATION TO ME. SIGNATURE OF APPLICANT: * for vulnerable sector searches only USCJ, 820 Second Ave, 10 th Floor, New York, NY 10017, USA Phone 1-212-533-7800 Fax 1-212-353-9439 3/2009
A Summary of Your Rights Under Canadian Legislation Canadian privacy legislation promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies and background checking companies. There are many types of consumer reporting agencies, including credit bureaus and specialty agencies. Here is a summary of your major rights under Canadian privacy legislation. Note that Sterling InfoSystems, Inc. DBA Sterling Testing Systems Inc. ( Sterling ) does not have ability to change information contained in your credit report or on your criminal record. To correct these types of information, please see the sections on disputing information below. You must be told if information in your file has been used against you. Anyone who uses a credit report or another type of consumer report to deny your application for credit, insurance, or employment or to take another adverse action against you must tell you, and must give you the name, address, and phone number of the agency that provided the information. You have the right to know what is in your file. You may request and obtain all the information about you in the files of a consumer reporting agency (your file disclosure ). You will be required to provide proper identification, which may optionally include your social insurance number. In many cases, the disclosure will be free. You are entitled to a free file disclosure if a person or company has taken adverse action against you because of information in your credit report. You have the right to dispute incomplete or inaccurate information. If you identify information in your file that is incomplete or inaccurate, and report it to the consumer reporting agency, the agency must investigate unless your dispute is frivolous. See the section on disputing information on your credit report for details. Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information. Inaccurate, incomplete or unverifiable information must be removed or corrected. However, a consumer reporting agency may continue to report information it has verified as accurate. Access to your file is limited. A consumer reporting agency may provide information about you only to people with a valid need -- usually to consider an application with a creditor, insurer, employer, landlord, or other business. You must give your consent for reports to be provided to employers. A consumerreporting agency may not give out information about you to your employer, or a potential employer, without your written consent given to the employer.
Disputing Information on a Canadian TransUnion Credit Report 1 Sterling InfoSystems, Inc. DBA Sterling Testing Systems, Inc. ( Sterling ) obtains credit reports in Canada from TransUnion. Sterling does not have ability to change information in your credit report. To dispute information regarding your credit report, follow the procedure below. TransUnion initiates an investigation of any credit information disputed by a consumer and recommends that you not apply for credit while a dispute is pending. Investigations are typically concluded within 30 days of the date we receive the request. If TransUnion cannot verify the disputed information within that time frame, the disputed item is deleted from your credit report or updated as requested. A notice, reflecting the results of the investigation, is sent to you by mail at the conclusion of the investigation. If our investigation does not resolve the dispute, you may add a 100-word explanatory statement to your report. Exception: 200 words in Saskatchewan. You may dispute any information on your credit report. Please include the following information: Name Current Address Previous Address (if less than 2 years at current address) Date of Birth Social Insurance Number (Optional) Employment information (optional) Telephone Number Name of the Company you have a dispute with (from your credit report) Account Number, if available, of the disputed item (from your credit report) Reason for your dispute (such as, it is not your account, you have paid the account, etc.) Any corrections to your personal information (supporting identification must be provided.) Mail your dispute to: Provinces Other than Quebec TransUnion P.O. Box338, LCD1 Hamilton, Ontario L8L 7W2 In Quebec TransUnion 1 Place Laval Ouest Suite 370 Laval, Quebec H7N 1A1 1 See http://www.tuc.ca for more information
Disputing Information on a Canadian Criminal Report 2 Sterling InfoSystems, Inc. DBA Sterling Testing Systems, Inc. ( Sterling ) obtains criminal records in Canada from the Royal Canadian Mounted Police (RCMP). Sterling does not have ability to change information in your criminal record. If you feel that there are mistakes on the criminal record or you are not the person to whom the record refers, please follow the procedure below. In Canada: If the criminal record does not refer to you, go to any local police station and request a certified criminal record check. The police station will require a full set of fingerprints, including both rolled and flat impressions of all ten fingers. Depending on the police jurisdiction, a fee may be required. The police station will issue you a certified criminal record immediately which you must take to your prospective employer. Once the employer receives the certified criminal record, they will review your application and make a decision. If any information on the criminal record is incorrect, contact your local police department for instructions on how to correct it. Once the record is corrected, follow the procedure above for obtaining a certified criminal record. Outside Canada: If the criminal record does not refer to you, you must request a certified criminal record check from the RCMP in Canada via mail by following the procedure below. Please note that it may take more than three months to obtain these records. If you need corrected records quickly, traveling to Canada and following the procedure above may provide an effective alternative. 1) Obtain fingerprints with the nearest police force which offers fingerprinting services. The RCMP will accept fingerprint forms from foreign countries that contain the following: rolled and flat impressions of all ten fingers taken with black ink full name, date of birth and sex of the applicant the name and address of the police agency the signature of the official taking the fingerprints. If the police service in your city or country does not have fingerprint forms for non-criminal purposes you can obtain an RCMP C-216C form by mail by contacting: RCMP Headquarters, 1200 Vanier Parkway, Ottawa, ON K1A 0R2. Phone: +1-613-993-7267 2) When requesting a certified criminal record check, clearly indicate that you are requesting it for employment purposes and specify the job title or position sought in the "REASON FOR APPLICATION" portion of the fingerprint form. 3) The processing fee is 25.00$CAN or 18.00$US, and is payable to the "Receiver General for Canada" by certified check or money order. 2 See http://www.rcmp.ca/crimrec/finger_e.htm for details
Location Date I, legal parent of, do hereby declare that I voluntarily agree to allow said child to have a background investigation conducted by Sterling Testing Systems, Inc. I do hereby waive in my behalf, and in behalf of my spouse and said child, all rights and do voluntarily agree that said background investigation should be performed and the results transmitted to for whatever use they may determine. In consideration of and as an inducement for Sterling Testing Systems, Inc. to perform a background investigation on my child, I and my spouse do hereby release Sterling Testing Systems, Inc., its officers and employees, and, its officers and employees, and agents from any and all liability whatsoever as a result of said child having a background investigation performed and the transmitting and utilization of the results thereof. Signature Of Legal Parent Or Guardian Print Name 249 West 17 th Street, 6 th Floor, New York, NY 10011 Telephone (212) 736 5100 (800) 899-2272 Facsimile (212) 736-0683 www.sterlingtesting.com 10/2003