Self-Declaration for
POLICE INFORMATION CHECK
Consent for Disclosure of Personal Information
PD 1244A (R2012-07)
If you have checked “yes” to question 14 ‘Have you ever been fingerprinted for a criminal offence in Canada for which you have not
received a pardon’ on the Police Information Check Application. Please list the following information on this Self-Declaration in order
to waive the fingerprint confirmation requirement to allow the Calgary Police Service, Police Information Check Unit to disclose this
information directly to yourself.
Please check off the appropriate boxes:
Have you been convicted of a criminal offence for which a pardon has not been granted?
Yes
No
Have you been granted a conditional discharge within the past three (3) years?
Yes
No
Have you been granted an absolute discharge within the past year?
Yes
No
If Yes, please provide details on ALL convictions (if more space is needed, please attach additional pages as required):
Offence
Disposition/Sentence
Date (YYYY/MM/DD)
Location of Court (city, town)
Offence
Date (YYYY/MM/DD)
Disposition/Sentence
Location of Court (city, town)
Offence
Date (YYYY/MM/DD)
Disposition/Sentence
Location of Court (city, town)
Offence
Date (YYYY/MM/DD)
Disposition/Sentence
Location of Court (city, town)
Disclaimer: The existence of a conviction will not preclude you from consideration for employment or a volunteer position. Details in this
self-declaration will enable the organization to which you are making application with to determine whether the offence is relevant to your
intended position.
I certify that the information in this Self - Disclosure of Personal Information is true and accurate to the best of my ability.
Date (YYYY/MM/DD)
Full Name (printed)
Signature
Personal information on this form is collected pursuant to the Freedom of Information and Protection of Privacy Act and the Police Act.
Questions or concerns should be directed to: CALGARY POLICE SERVICE POLICE INFORMATION CHECK UNIT at 403-428-2052.