Application Form Fill in the fields below to apply to become a Citizen on Patrol If you are human, leave this field blank. Personal Information Current Date * First Name * Last Name * Email Address Address * Apt No. (if applicable) City * Province ON QC AB BC MB NB NL NT NS NU PE SK YT Postal Code * Home Phone No. * Cell Phone No. * Eligibility Are you legally elgible to work in Canada? * Yes No Have you ever been convicted of a criminal offence for which a pardon has not been granted? * Yes No Are you 18 years of age or older? * Yes No Do you have a valid drivers license? * Yes No Are you able to provide volunteer service on a monthly basis totaling a minimum of 36 hours annually? * Yes No Have you worked/volunteered here previously? * Yes No What Position? * Start Date * End Date Leave blank if currently an employee Past Employement Please List all previous employers Employer Involvement Employee Volunteer Phone No. Address City Province ON QC AB BC MB NB NL NT NS NU PE SK YT Job Title Supervisor's Name Do you currently work/volunteer there? Yes No Start Date End Date May we contact this current employer? Yes No Briefly Describe Your Duties Reason for Leaving May we contact this employer? Yes No Add Employment Remove Character References Three people whom we may personally contact or write a character reference. (DO NOT LIST RELATIVES, FORMER EMPLOYEES, PRIESTS, PASTORS, MINISTERS OF RELIGION, OR POLITICAL LEADERS) Name * Home Phone No. Business Phone No. Address * Relationship (ie: coworker, friend) * Years known * Name * Home Phone No. Business Phone No. Address * Relationship (ie: coworker, friend) * Years known * Name * Home Phone No. Business Phone No. Address * Relationship (ie: coworker, friend) * Years known * Terms and Conditions Agreement I agree to the Terms and Conditions of the Brantford Citizen's on Patrol Program, as outlined below Personal information relating to the recruitment and selection process is collected under the authority of the Police Services Act and will be used to determine suitability as a volunteer with the Brantford Police Service Citizen on Patrol Program. Information is subject to verification and confirmation with corresponding documents at any time. Continuation in the selection process is dependant upon the receipt of various documents at different stages. Questions about this collection of personal information should be directed to the Community Safety and Crime Prevention Section of the Brantford Police Service. I confirm that the information given is true and correct to the best of my knowledge. I authorize the BRANTFORD POLICE SERVICE to collect personal information concerning myself including academic records, pre-volunteer testing results and assessments, aptitude test(s) results, work history, disciplinary records, financial records, character statements, and non- pardoned criminal records from sources other than myself. Furthermore, I hereby absolve and save harmless members of the BRANTFORD POLICE SERVICES BOARD, the BRANTFORD POLICE SERVICE and all its individual employees from all liability, cause of action, or damages resulting from the release of any or all such information. I agree to comply with all BRANTFORD POLICE SERVICE directives, Rules and Regulations, safety procedures, the Ontario Police Services Act and other Terms and Conditions of volunteer service as may be instituted or revised by the BRANTFORD POLICE SERVICE from time to time. REFERENCES: For employment and/or character references, I Authorize the BRANTFORD POLICE SERVICE to contact and collect information concerning my job performance and character from employers/supervisors and persons named herein. The persons named herein may furnish information they may have concerning my suitability for the position applied for to the Brantford Police Service, and I do release such individual from any and all liability by reason of furnishing such information. I agree and understand that any misrepresentation of facts shall constitute just cause for the termination of my volunteer service and/or association with the BRANTFORD POLICE SERVICE, at any time. Furthermore, I agree and understand the information obtained through background investigation checks concerning job performance and character references from employers, supervisors, and those named herein is a confidential process. Information obtained through background investigation will not be available to me or my representative.