LONDON POLICE SERVICE APPLICATION FORM

LONDON POLICE SERVICEAPPLICATION FORMCONSTABLE CADET AUXILIARYCIVILIAN - Position applied for:Are you legally eligible to work in Canada?SURNAMEGIVEN NAMESADDRESS (Street, P.O. Box, Lot / Concession No.) CITY POSTAL CODEHOME TELEPHONE NO.BUSINESS TELEPHONE NO.HIGHEST GRADE / LEVEL COMPLETEDPOST SECONDARY SCHOOL EDUCATIONDO YOU HAVE TYPING / COMPUTER EXPERIENCE? NO YES - W.P.M.BRIEFLY EXPLAIN WHY YOU WOULD LIKE TO BE A MEMBER OF THE LONDON POLICE SERVICE ORGANIZATION:APPLICANT'S SIGNATURE:DATE:NOTE: Individuals who submit false information, or do not meet the requirements, can be disqualifiedfrom further consideration for employment, or dismissed, if already employed.Notice: Personal information on this form is collected under the authority of the Police Services Act, S38, S43 & S53and will be used to determine eligibility for employment. Questions about this collection of personal informationshould be directed to the address listed below.NOTE: Persons interested in Constable positions should forward their O.A.C.P. certificate of results and A.T.S.scoring profile, all formal education mark transcripts / diplomas, four letters of reference, Standard First Aid andC.P.R. certificates and a complete resume in addition to this application form to;London Police ServicePersonnel Services Branch601 Dundas StreetLondon, ONN6B 1X1Only those selected for an interview will be contactedForm No. LP 630 (Rev. 06/06)

AUTHORIZATION FOR THE COLLECTION OFINFORMATION (POLICE APPLICANT)I,_______________________________________________________authorize the London Police Service to collect from any physician, psychologist, employer,organization or person to whom a signed copy of this authorization or a photocopy or fax thereofis delivered, to provide any information, opinion, reports. records, documents, or copies thereofin any form which may be requested in connection with my application for employment with anypolice service in Canada, and any subsequent training and employment.I understand that personal information about me, including but not limited to academic,employment history including disciplinary records, medical, physical, financial, character, andcriminal record data from sources other than myself will be collected through the selectionprocess under the authority of Section 43 of the Police Services Act, and with my consent.I understand that information about me will be used to assess my qualifications and suitability inrelation to my application for employment as a police officer. Any information collected is theproperty of the London Police Service.I consent to the collection, use, disclosure, transmittal and examination by the London PoliceService, or any other police service requesting this material, of all information compiled aboutme, including: academic records and transcripts, employment records, police records and historyof law involvement, police service applications, medical information, background and securitychecks, financial information including credit bureau check, driving record, physical,psychological, visual, aptitude, and other employment related tests and interview informationprovided during the selection process, training records, and police service performance reviewrecords. I further consent to a criminal record check for a sexual offence for which a pardon hasbeen granted or issued.I further understand that any questions I may have concerning the collection, use or disclosure ofthis information should be addressed to: Inspector, Personnel Services Branch, London PoliceService, 601 Dundas Street, London, Ontario, N6B-1X1, 519-661-5660._____________________DATEForm No. LP713 (06/00)__________________________SIGNED__________________________WITNESS