Business Account Application

Version 1.0

February 22, 2017

tf 1.866.466.4043 w dcbank.ca

BUSINESS ACCOUNT APPLICATION FORM | 2017

1 |

Business Account Application Form

Welcome to DC Bank

A Business Account at DC Bank can be opened in a few simple steps. To better understand your banking needs and for us to know your business, we have developed this application form. Please be sure to read all of the instructions and go through the form carefully. It is important to fully complete the application. Missing information could cause delays.

Application Requirements

Please note that all sections in this application are mandatory, except where the section is not applicable to the applicant’s business type. Your completed application should include the following:

Section Title Completed

1 Applicant Information filled out completely (this form completed) ☐

2 Required Identification Documentation (legible copies attached) ☐

3 Banking Resolution (from page 9 of this application) ☐

4 Financial Statements ☐

5 Pre-Printed Business Cheque from another institution you have an account with ☐

6 Trade References (page 11 of this application) ☐

Please forward the above documentation to:

Via Mail: Via Email: Via Fax:

DirectCash Bank 736 Meridian Road NE Calgary, Alberta T2A 2N7

newaccounts@dcbank.ca 1-866-350-2160

Questions? If you have any questions about this application, please contact the DC Bank New Accounts Department:

Toll-Free number: 1-888-301-1907 Fax: 1-866-350-2160 E-mail: newaccounts@dcbank.ca

tf 1.866.466.4043 w dcbank.ca

BUSINESS ACCOUNT APPLICATION FORM | 2017

2 |

Section 1: Applicant Information Form

Applicant Information

Legal Name of Business:

Business Identification Number (BIN), Quebec Enterprise Number (NEQ), or Social Insurance Number (for business that does not have a BIN or NEQ, ie. Sole Proprietorships)1

Head Office Address (number, street, apartment) City: Province: Postal Code:

Business Phone Number Ext. Fax #

Type of Business

Residency for Tax Purposes (choose one only) ☐ Canada (include province below) ☐ U.S. (include state below) ☐ Other (include country below)

Country of legal formation: ☐ Canada ☐ U.S. ☐ Other (please specify):

Preferred language: ☐ English ☐ French

Type of Entity

☐ Corporation ☐ Investment Club ☐ Estate ☐ Informal Trust

☐ Condominium Corporation ☐ Partnership (includes personal assets, commercial) ☐ Complex Trust ☐ Individual Pension Plan (IPP)

☐ Union ☐ Pension Fund ☐ Grantor Trust ☐ Government/International Organization

☐ Personal Holding Company ☐ Investment Counsellor/Portfolio Manager ☐ Simple Trust ☐ Private Foundation

☐ Tax Exempt Organization (Includes Charity – CRA Registered, Not for Profit – CRA Registered)

☐ Does the entity (including parent company or subsidiaries) have, or intend to have, operations or conduct business outside of Canada or the U.S.?

☐ No ☐ Yes (if yes, indicate which country(ies) and explain business:

Describe all Nature of Business/Industries of the Entity2 (a minimum of one nature of business/industry is required)

Primary:

Secondary:

Tertiary:

1 The Business identification number is a 9-digit number issued by the federal government for income tax purposes. The Quebec Enterprise Number is a 10-digit number issued in Quebec for GST/TVQ reporting purposes. The Incorporation Number (or Corporation Registration Number), required only for corporate applicants, is issued by the federal or applicable provincial government(s) upon registering the corporation 2 Be as clear as possible in describing the primary function or activity of the Business. For example, descriptions such as “administration” or “manufacturer” do not sufficiently describe the function or the activities of the Business. Descriptions such as “payroll administration services” or “car manufacturer” are acceptable.

tf 1.866.466.4043 w dcbank.ca

BUSINESS ACCOUNT APPLICATION FORM | 2017

3 |

Beneficial Owners

List all shareholders and provide complete details:

1

Name: Home Address:

Date of Birth: Occupation: % Ownership:

How Shares are Held:

2

Name: Home Address:

Date of Birth: Occupation: % Ownership:

How Shares are Held:

3

Name: Home Address:

Date of Birth: Occupation: % Ownership:

How Shares are Held:

4

Name: Home Address:

Date of Birth: Occupation: % Ownership:

How Shares are Held:

5

Name: Home Address:

Date of Birth: Occupation: % Ownership:

How Shares are Held:

6

Name: Home Address:

Date of Birth: Occupation: % Ownership:

How Shares are Held:

7

Name: Home Address:

Date of Birth: Occupation: % Ownership:

How Shares are Held:

Are shares of the entity traded on a public stock exchange? Yes ☐ No ☐

tf 1.866.466.4043 w dcbank.ca

BUSINESS ACCOUNT APPLICATION FORM | 2017

4 |

Director Information3

Please complete the information below for all the directors of the Business. If additional space is required, please attach a separate sheet. For corporations, partnerships, condominium operations or trade/labor unions.

For occupation, please be as specific as possible, e.g., Manager of Sales for a software company.

1

Name: Occupation:

Phone #: Email:

2

Name: Occupation:

Phone #: Email:

3

Name: Occupation:

Phone #: Email:

4

Name: Occupation:

Phone #: Email:

Applicant Operations

Does the entity conduct any of the following activities?

Operate as a Non- Registered Charity or Not for Profit Organization ☐ No ☐ Yes

Operate a Money Service Business. If YES, License/Registration #: ____________________________ ) ☐ No ☐ Yes

Operate a Cheque Cashing/Payday Lending Business. If YES, License/Registration #: ___________________________ ☐ No ☐ Yes

Operate and load a White Label banking machine(s) ☐ No ☐ Yes

Buy or sell or deal in precious metals, gems or fine jewellery (domestically or internationally) ☐ No ☐ Yes

Operate a casino, bingo, or gambling/gaming service. If YES, License/Registration #: __________________________ ☐ No ☐ Yes

Operate an internet gambling business. If YES, License/Registration #: ☐ No ☐ Yes

Sell used cars, boats or airplanes ☐ No ☐ Yes

Operate as an arms manufacturer, dealer or intermediary ☐ No ☐ Yes

Create or operate as an exchange/exchanger of Bitcoin or other crypto/virtual currencies ☐ No ☐ Yes

Operate a telemarketing/direct marketing business (sell goods/services via telephone or the internet) ☐ No ☐ Yes

Operate a pawn broker service ☐ No ☐ Yes

Operate a Trust, Private Investment Company, or Personal Holding Company formed outside of Canada or the U.S. If YES, License/Registration #: ☐ No ☐ Yes

Operate a Correspondent Bank. If YES, License/Registration #: ☐ No ☐ Yes

Operate a Shell Bank. If YES, License/Registration #: ☐ No ☐ Yes

Operate as a medical marijuana licensed producer. If YES, License/Registration #: ☐ No ☐ Yes

Operate an account for a Foreign Government ☐ No ☐ Yes

(if yes, indicate which country)

3 If additional space is required, attach a separate sheet.

tf 1.866.466.4043 w dcbank.ca

BUSINESS ACCOUNT APPLICATION FORM | 2017

5 |

Self-Certification – Foreign Account Tax Compliance Act (FATCA)

For more information on the Canada Revenue Agency Enhanced Financial Account Information Reporting and the U.S. Foreign Account Tax Compliance Act (FATCA), please refer to the Canada Revenue Agency website or consult your legal tax advisor

Select one of the following:

Non-U.S. Non-Financial Entity

☐ Active Non-Financial Entity (e.g., more than 50% of income is generate from an active trade or business; more than 50% of assets are used in an active trade or business; registered charity; government; publically traded corporation)

☐ Passive Non-Financial Entity (e.g., more than 50% of income is passive or investment income; more than 50% of assets are used to generate passive or investment income)

Does the client have any U.S. Controlling Persons (U.S. beneficial owners)? ☐ No ☐ Yes (if yes, please complete the Beneficial Ownership Information Form)

U.S. Entity

☐ Specified U.S. Entity (organized or incorporated in the U.S. other than entities listed under “Other U.S. Entity”)

U.S. Taxpayer Identification Number (TIN)

☐ Other U.S. Entity (e.g., publicly traded U.S.)

Does the client have any U.S. Controlling Persons (U.S. beneficial owners)? ☐ No ☐ Yes (if yes, please complete the Beneficial Ownership Information Form)

Non U.S. Financial Institution (FI)

☐ Reporting Canadian Financial Institution or Partner Jurisdiction Financial Institution

Global Intermediary Identification Number (GIIN)

☐ Participating Foreign Financial Institution

Global Intermediary Identification Number (GIIN)

☐ Registered Deemed Compliant Financial Institution

Global Intermediary Identification Number (GIIN)

☐ Non-Reporting Canadian or Partner Jurisdiction Financial Institution

☐ Certified Deemed Compliant Financial Institution

☐ Non-Participating Financial Institution

tf 1.866.466.4043 w dcbank.ca

BUSINESS ACCOUNT APPLICATION FORM | 2017

6 |

Authorized Signing Officer Information4

Please complete the information below and indicate the two (2) types of documentation viewed (at least one must be government issued) to verify the identity of each of the Authorized Signing Officers named below (maximum of three).

Officer #1 First Name: Last Name: Date of Birth (mm/dd/yyyy): Occupation/Title:

Home Address: City: Province: Postal Code:

Home Phone #: Business Phone #: SIN (Optional):

Type of Identification: Identification #: Place of Issue: Expiry Date:

Are you a Politically Exposed Person (PEP)? See definition below. 5 Yes: ☐ No: ☐

Officer #2 First Name: Last Name: Date of Birth (mm/dd/yyyy): Occupation/Title:

Home Address: City: Province: Postal Code:

Home Phone #: Business Phone #: SIN (Optional):

Type of Identification: Identification #: Place of Issue: Expiry Date:

Are you a Politically Exposed Person (PEP)? See definition below. Yes: ☐ No: ☐

Officer #3 First Name: Last Name: Date of Birth (mm/dd/yyyy): Occupation/Title:

Home Address: City: Province: Postal Code:

Home Phone #: Business Phone #: SIN (Optional):

Type of Identification: Identification #: Place of Issue: Expiry Date:

Are you a Politically Exposed Person (PEP)? See definition below. Yes: ☐ No: ☐

Officer #4 First Name: Last Name: Date of Birth (mm/dd/yyyy): Occupation/Title:

Home Address: City: Province: Postal Code:

Home Phone #: Business Phone #: SIN (Optional):

Type of Identification: Identification #: Place of Issue: Expiry Date:

4 If the Business has more than three Authorized Signing Officers, Personal information for the three primary individuals that will be providing instructions on the account is required to be completed in the Application. DC Bank staff must view the original, valid and unexpired identification documents that verify the identity of these individuals. Applicants must provide a valid government issued piece of photo identification bearing the individual’s likeness and signature (example: Canadian passport or driver’s license). If you are unsure of what acceptable identification is, please call the Bank’s Support Center at 1-888-466-4043 for a complete listing of acceptable identification document types. 5 "Politically Exposed Person" ("PEP") means (A) any person who holds or has ever held one of the following offices or positions in or on behalf of a country: (1) a head of state or government, (2) a member of the executive council of government or member of a legislature, (3) a deputy minister (or equivalent), (4) an ambassador or an ambassador's attaché or counsellor, (5) a military general (or higher rank), (6) a president of a state owned company of bank, (7) a head of a government agency, (8) a judge, or (9) a leader or president of a political party in a legislature; or (B) any of the following family members of an individual described in (A)(1)-(9): (i) mother, (ii) father, (iii) spouse, (iv) common law partner, (v) spouse's or common law partner's mother or father, (vi) brother, (vii) sister, (viii) half-brother, or (ix) half-sister, (in all cases regardless of citizenship, residence status, or birth place).

tf 1.866.466.4043 w dcbank.ca

BUSINESS ACCOUNT APPLICATION FORM | 2017

7 |

Regulatory Information

This section must be completed

Will this account be used by, or on behalf of, a third party?6 If yes, please provide information below: Yes: ☐ No: ☐

Name: Address: Phone #:

Contact email: What is the intended use of the account?7

Personal Information

The Business authorizes the Bank to obtain, verify, give, share and exchange personal information, including the release of this Application, about the persons identified as Authorized Signing Officers for the Account and/or those individuals that have signed this Application and information about the Business, now and in the future, with any individuals, financial institutions, business corporations or other parties with whom the Business has or proposes to have financial dealings, or who hold information about such dealings, such as credit bureaus. Such information will be used for the purpose of confirming identity and assessing the financial situation of the Business, administering and maintaining the Business’ financial records, supporting and maintaining the accuracy and the integrity of the credit reporting system, and as may be otherwise permitted or required by law. The Business also authorizes any person that the Bank contacts to provide such information. The Business authorizes the Bank to record its telephone conversations for the administration of the Account and to maintain quality service levels.

The Business acknowledges that it has read and understands the Personal Information Statement in the Account Operating Agreement and consents to the collection, use and disclosure of information in accordance with the terms of the Personal Information Statement.

The Business confirms that any individual who has provided their personal information, in connection with this Account, has consented to the collection, use and disclosure as provided for in this Application and under the Personal Information Statement.

The Business may contact the Bank’s Customer Service Centre at 866-466-4043 for additional information relating to the Bank’s privacy policies and regarding options for withdrawing consent.

Signature(s)8

The undersigned Authorized Signing Officer(s) of the applicant Business agree(s), acknowledge(s) and certifies, by signing this Application, that:

The information provided is true and complete. In order to keep the file current, the Business undertakes to advise the Bank of any changes to the information provided in this Application. The Business has been provided with the Account Operating Agreement and the “Welcome to DirectCash Bank” brochure that sets out the charges

applicable to the Account. Further, the operation of each account which the Business now or hereafter has with the Bank and the carrying on of other banking business by the Business with the Bank shall be subject to the terms and conditions in this Application and the terms and Conditions of the Account Operating Agreement, all of which shall constitute a duly executed agreements between the Business and the Bank to which the Business agrees to and is bound.

Cheques and other vouchers will not be returned to the Business. The Bank does not verify signatures on cheques prior to clearing them. The Bank is entitled to relay on this executed application as duly and validly authorized and binding on the Business. For businesses other than

Corporations, the Bank does not need to make any further inquiry into the authority of the Authorized Officers to bind the Business. The Business requests that the Bank open the Account for the Business.

Please indicate how many signatures are required to transact on the account:

Indicate Number

Dated at: this: day of: Year:

Authorized Signing Officer’s Signature: Name: Title:

Authorized Signing Officer’s Signature: Name: Title:

Authorized Signing Officer’s Signature: Name: Title:

6 If the account will be opened for, or will be used by, another person or entity, then select the “Yes” box and provide the Third Party’s name, address, date of birth, principle business or occupation, incorporation number and place of issue (if applicable) and the relationship with the Account Owner. 7 The Bank is required by law to determine the use of the account. Answers of “Unknown” or “Not Applicable” are unacceptable and will result in processing delays 8 Please indicate how many signatures will be required to provide instructions or sign cheques on the account. Only individuals authorized to open the account should sign this section. Note that in some companies or businesses, these individuals may not be the same as the appointed Authorized Signing Officers. For example, some companies may only allow certain Officers to open an account, such as the President, Chief Financial Officer or Treasurer, but will allow other Officers to operate the account.

tf 1.866.466.4043 w dcbank.ca

BUSINESS ACCOUNT APPLICATION FORM | 2017

8 |

Section 2: Required Identification Documentation

Identify your type of business below and provide to corresponding required identification documents: ☐ ☐

Type of Business Identification Documentation Required Included Not Applicable

Corporation (Examples include for-profit businesses, public bodies such as municipalities, cities and hospitals and incorporated not-for-profit organizations such as churches, charities and associations)

1. Please complete the Banking Resolution (included in section 3) and have it ratified by the Board of Directors.

The Bank will confirm existence of the entity by searching various government databases. If search results are not acceptable, additional documentation may be required.

☐ ☐

2. Copy of articles of incorporation or certificate of incorporation. ☐ ☐

Partnership 1. A current list of all beneficial owners ☐ ☐

2. Information regarding the partners which may include information required for corporations or partnership agreements. ☐ ☐

Sole proprietorship 1. Name of principal/owner. ☐ ☐

2. A copy of your latest CRA Notice of Assessment. ☐ ☐

Charitable or not-for-profit organization (examples include a club, association, society, lodge or church)

1. Copy of provincial or federal registration or other constituting documents (i.e. articles of association, charter, by-laws). ☐ ☐

2. Copy of CRA registration and number for registered charity. ☐ ☐

tf 1.866.466.4043 w dcbank.ca

BUSINESS ACCOUNT APPLICATION FORM | 2017

9 |

Section 3: Banking Resolution9

To: DirectCash Bank (“The Bank”)

The undersigned certifies:

That the following is true copy of the resolutions duly passed on the

day of

By the Director(s) of Corporate Name (Hereinafter called the “Corporation”) and that said resolutions are now in full force and effect: RESOLVED:

1. THAT DirectCash Bank (hereinafter called the “Bank”) is appointed one of the bankers of the Corporation.

2. THAT any *of the Authorized Signing Officers of the Corporation identified below (is/are) authorized on behalf of the Corporation to sign such agreements and other documents and deliver such instructions as may be required by the bank in accordance with the Account Agreement and the Business Account Application to provide the selected banking services to the Corporation.

3. THAT these Resolutions shall be irrevocable until alternate Resolutions shall have been passed and a certified copy delivered to the Bank.

4. THAT the following are the Authorized Signing Officer(s) of the Corporation:

Title Name Specimen Signature

The undersigned certifies that the foregoing Banking Resolution is a true copy of a resolution properly passed by the Board of Directors of the Corporation and that the said resolution is now in full force and effect and that the Bank may act upon them until the Bank is notified in writing to the contrary.

Certified at this day of

(City/Town) (month) (year)

Authorized Officer of the Company signature:

9 Complete the Banking Resolution appointing the Authorized Signing Officers. The Banking Resolution must be ratified by the Corporation’s Directors and must be signed by a person authorized to certify the Banking Resolution (usually the Corporate Secretary or President).

tf 1.866.466.4043 w dcbank.ca

BUSINESS ACCOUNT APPLICATION FORM | 2017

10 |

Section 4: Financial Statements

Financial Statements

Provide copies of your most recent interim financial statements and last two full years. Interim year: ☐

Provide the name and contact information for the statement auditor. Full years: ☐

Name: Phone #:

E-mail:

Section 5: Pre-Printed Business Cheque

Pre-Printed Business Cheque

Provide a pre-printed business cheque with the full business name, drawn from another account of the Business at a Canadian financial institution, made payable to the Business for any amount as your initial deposit,

or

A VOID pre-printed business cheque or bank account confirmation form completed by your bank in the existing business account in the same name, if you have completed the funds transfer section.

☐

ATTACH VOID CHEQUE

tf 1.866.466.4043 w dcbank.ca

BUSINESS ACCOUNT APPLICATION FORM | 2017

11 |

Section 6: Trade References

Provide three trade references, these can be suppliers, bankers etc.

Reference #1 Name: Contact: Title/Occupation:

Address: City: Province: Postal Code:

Phone #: Fax #: E-mail:

Annual value of purchases (CDN $): Doing Business Since:

Reference #2 Name: Contact: Title/Occupation:

Address: City: Province: Postal Code:

Phone #: Fax #: E-mail:

Annual value of purchases (CDN $): Doing Business Since:

Reference #3 Name: Contact: Title/Occupation:

Address: City: Province: Postal Code:

Phone #: Fax #: E-mail:

Annual value of purchases (CDN $): Doing Business Since:

Background Check Forms

Version 1.0

February 22, 2017

tf 1.866.466.4043 w dcbank.ca

SUPPLEMENTARY DATA COLLECTION FORM | 2017

1 | This document is confidential. Any unauthorized use is prohibited. If it is received in error, please call 1-866-455-5671.

Background Check Requirements

Please complete all sections of the Background check below and return to Direct Cash with two pieces of identification for each Officer/Director.

The first form of identification must be government issues and include the applicant’s first and last name, date of birth, photo and signature. The

second form of identification does not need to be government issued. At minimum it must include the applicants first and last name.

Note that all sections in this application are mandatory.

Section Title Completed

1 Corporate Information filled out completely ☐

2 Privacy Notice (please review carefully) ☐

3 Criminal Record Check (please review carefully) ☐

4 Consent for Collection, Use and Disclosure of Personal Information (please review and sign) ☐

5 General Information (to be completed by all officers and directors) ☐

tf 1.866.466.4043 w dcbank.ca

SUPPLEMENTARY DATA COLLECTION FORM | 2017

2 | This document is confidential. Any unauthorized use is prohibited. If it is received in error, please call 1-866-455-5671.

1. Corporate Information (Please complete clearly in capital letters)

Legal Name:

Doing business as:

Telephone: Website:

Mailing Address (unit number, street number, street, city/town, province/state, country):

Physical Address, if different from Mailing Address (unit number, street number, street, city/town, province/state, country):

Jurisdiction of Incorporation (province/state, country): Date of Incorporation (yyyy/mm/dd):

EIN/FEIN (if applicable): WCB/WSIB number (if applicable):

2. Privacy Notice (Applicant: Please read the following sections carefully)

To evaluate your suitability for employment or another business relationship, DCBank (“the Company”) will ask Sterling Talent Solutions Canada Corp. and its parent, affiliates and

subsidiaries (“Sterling”, “we” or “us”) to create a background check report or reports (“Reports”) consisting of one or more background check services (“Services”). Collection: We may collect

the following types of personal information about you: identification information and documents; photograph; address history; police records; court records; employment history, including

fiduciary or directorship responsibilities; education history; financial information, including credit history, bankruptcy and financial judgments; driving records; membership, registration or

disciplinary action with regulatory or professional bodies; inclusion on watch or sanctions lists; social media activity; mentions in online or print media; or opinions about your performance,

qualifications and character. We may collect personal information directly from you, the Company, or third parties such as police, courts, employers, educational institutions, consumer

reporting agencies, government agencies, regulatory or professional bodies, references you provide and publicly available print or online sources. We may compare information received

from different sources for consistency. The exact types and sources of personal information will depend on the Services requested by the Company. Use: Our data entry, order fulfillment,

quality assurance, client service, finance and compliance teams may use your personal information to complete Services, prepare Reports and communicate with you or the Company. These

teams include our employees in Canada, the Philippines, India and the United Kingdom. Personal information may be transferred to additional countries if we need to collect personal

information from those countries or use a language other than English or French. Wherever your information is transferred, it will be handled in accordance with our privacy and security

policies and Canadian laws, but it may also be subject to foreign laws. Disclosure: We will disclose your personal information to the Company. We may also disclose information, such as your

name, date of birth, identifying numbers, signature, contact information, and relationship with the Company, to third parties as necessary for them to provide your personal information to

us. Storage and retention: We will store your personal information on servers located in Calgary, Alberta, Canada. We will keep your personal information for as long as we need it to

complete the Services, deliver and maintain Reports for the Company and fulfill our legal and contractual obligations, after which it will be destroyed. Your rights: You have a right to access

your personal information, dispute its accuracy or completeness, be told its sources and to whom it has been disclosed, and modify or withdraw your consent for its collection, use and

disclosure. You have a right to ask questions or complain about how we handle your personal information. To do any of these things, contact one of our Privacy Analysts at

privacy@sterlingts.com, 1-866-455-5671 or Suite 200, 19433 96 Ave, Surrey BC V4N 4C4. For more information about our privacy and security policies, go to www.sterlingts.com/privacy. To

understand what Services will be ordered, why Reports are being requested, what will be done with personal information disclosed to the Company, or the consequences of not providing

your personal information, please speak to your contact with the Company.

3. Canadian Criminal Record Check

If a Canadian Criminal Record Check is requested by the Company, a search of the Royal Canadian Mounted Police (RCMP) National Repository of Criminal Records will be conducted by a

Canadian police service on our behalf through the Identification Data Bank of the Canadian Police Information Centre (CPIC) using your name(s), date of birth and declared criminal record.

The result will indicate whether a criminal record exists that may match your personal information, and whether your declared criminal record is a complete and accurate match to the

record on file. In some cases, the search may be inconclusive. We will not receive details of your criminal record other than those you provide. Only the submission of your fingerprints to

the RCMP can result in the release of a Certified Criminal Record and resolve inconclusive or disputed results. For more information, please contact one of our Privacy Analysts using the

contact information above.

4. Consent for Collection, Use and Disclosure of Personal Information (Applicant: Please read and sign)

By signing below, I acknowledge that I have read the privacy notice above and consent to the collection, use and disclosure of my personal information as described in it, effective

immediately and continuing for a period of one (1) year. I certify that personal information provided to Sterling and the Company is complete and accurate to the best of my knowledge, and

I understand that providing inaccurate, incomplete or misleading information may disqualify me from consideration by the Company.

Applicant Signature: Date (yyyy/mm/dd):

Print Full Name:

tf 1.866.466.4043 w dcbank.ca

SUPPLEMENTARY DATA COLLECTION FORM | 2017

3 | This document is confidential. Any unauthorized use is prohibited. If it is received in error, please call 1-866-455-5671.

5. General Information (Applicant: Please print clearly in capital letters) First Name: Middle Name:

Last Name: Date of Birth (yyyy/mm/dd):

Other First Name(s) Used (nickname, former name, etc.): Other Middle Name(s) Used:

Other Last Name(s) Used (maiden name, former name, etc.):

Current Address (unit number, street number, street, city, postal code, country):

Email Address: Telephone Number:

Previous Addresses (Applicant: Please provide 5 years of address history if a Canadian criminal record check is requested. Please use an additional page if necessary)

Previous address (unit number, street number, street, city, postal code, country): Years at this address (yyyy-yyyy):

Previous address (unit number, street number, street, city, postal code, country): Years at this address (yyyy-yyyy):

Canadian Criminal Record Check (Applicant: Please complete if a Canadian Criminal Record Check is requested)

Place of Birth (province/state and country): Sex:

Female ☐ Male ☐ Other ☐

Have you been convicted of a criminal offence for which a pardon or record suspension has not been

granted? Yes ☐ No ☐

What should you disclose? All criminal offences (offences under the Criminal Code of Canada, the Controlled Drugs and Substances Act or other federal laws that designate criminal

offences) for which you have been convicted as an adult and have not received a pardon or record suspension. What should you NOT disclose? Offences for which you have not been

convicted, such as pending or dismissed charges, acquittals or absolute or conditional discharges; convictions where you were considered a “young person” under the Youth Criminal Justice

Act or its predecessors; provincial or municipal offences such as speeding or parking tickets; charges dealt with outside of Canada; and convictions for which you have received a pardon or

record suspension.

Name of Offence Date of Conviction (yyyy/mm)

If you have other offences to disclose, please provide them on an additional page.

Social Insurance Number (Applicant: Please complete if a Canadian Credit Inquiry or SIN Validation is requested)

Providing your SIN is OPTIONAL. If a Canadian Credit Inquiry or a SIN Validation is

requested, your SIN may help us find your credit file or validate your SIN. If these

services are not requested, please do not provide your SIN.

Social Insurance Number:

☐ I decline to provide my SIN