PINOBOLA-Plumitif-English-LME

RENSEIGNEMENTS PERSONNELS
IMPORTANT
- Vous devez inscrire votre nom exactement comme sur vos cartes d'identité. Une information erronée sera considéré comme une fausse déclaration.
- Prenez le temps de bien inscrire vos informations.
Name:*
Surname:*
Date of birth:*
Format (dd/mm/yyyy)
E-Mail:*
Province :*
Phone number:*
2nd Phone Number

Enlightened consentement 1 of 3
Confirmations :*
- I hereby give authorization to Quali-T HR Services and Solutions (QTHRSS) and the applicants to obtain any of the information mentioned below and to use and/or disclose such resulting information or related information to the requestor of the above-named organization for the purpose of evaluating my application.
- An audit of the criminal and civil criminal court record obtained following a search conducted on the computerized system of the Quebec Ministry of Justice;
- A search of the RCMP's National Criminal Records Inventory based on the name (s), date of birth and, if applicable, the criminal record I provided.

Enlightened consentement 2 of 3
Confirmation*
- I understand that this information will be kept in a confidential manner by QTSSRH and the applicant or agent in accordance with federal, provincial, territorial and municipal privacy policies, and furthermore I understand that after the disclosure of this information, police and the institutions mentioned are in no way responsible for the use, application and / or dissemination of the information..
- I acknowledge that records and / or information found and / or disclosed by police services are not neccessarily mine and may

Enlightened consentement 2 of 3
Confirmations :*
- I certify, to the best of my knowlodge, the veracity and accuracy of the information I have provided herein. Before signing this authorization, I read it and fully understand all the clauses and their scope.
Applicant's signature:*
Quali-T Services et solutions RH, 65, avenue Liberté, Candiac, (Québec) J5R 3X8 Téléphone : 450.445.4969 Sans frais : 1.888.345.2887 Télécopieur 450.444.4963 **L’information relative à cette vérification de casier judiciaire est recueillie, conservée et communiquée conformément aux lois applicables en matière de protection des renseignements personnels. * Vérifications préemploi Quali-T Services et solutions RH, une division de Gestion Pergebec Inc.

INFORMATION