LONDON POLICE SERVICE APPLICATION FORM

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