Form No. 2: Consent to the Release of Personal Information

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Instructions

  1. Before completing any forms, please review the How to Apply page.
  2. Forms cannot be completed online. They must be printed, completed and mailed to:
    Minister of Justice
    Criminal Conviction Review Group
    284 Wellington Street
    Ottawa, Ontario
    K1A 0H8

Please Print

I, [name],

of [city, town, municipality],

in the province of ,

was convicted for [name of offence]

in relation to [specifics of offence]

on [date of conviction].

I consent to the release of any personal information or documentation (including medical, psychological or psychiatric records) relating to me that is in the possession of or under the control of any person, body or institution, to any designated representative of the Minister of Justice to assist in assessing my application for a conviction review under sections 696.1 to 696.6 of the Criminal Code.

I also consent to the disclosure to any person, body or institution of my personal information obtained in the course of reviewing my application in order for the Minister to obtain from that person, body or institution any information that is required for assessing my application.

Applicant's Signature

Date

Witness's Signature

Date

Full Name of Witness

Province

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