Application for Pre-Authorized Credit Card Usage - Ministry of Justice

Directions: You may complete the form fields at your computer, print, then sign and date OR print the form out and complete using a dark ink pen, printing clearly and carefully. The form must be signed and dated and all information must be complete in order for the record check to proceed. Incomplete forms will be returned. Credit card information should not be e-mailed.Mail or fax this form to the Criminal Records Review Program (address below). PART A – CREDIT CARD PAYMENT AUTHORIZATION I authorize the use of the following credit card to cover criminal record check(s) fees as follows (check one): Payment Type: p Visa p Mastercard p I hereby authorize to deduct $20.00 for each applicant listed in

Part B — $ ______________ (total payment authorized). p I wish to establish a drawdown account. p I wish to replenish an existing drawdown account. Credit Card Number: Expiry Date: ______ / ______ Print Cardholder’s Last Name: First Name: Signature of Cardholder: Date signed: _______ / _______ / _______ Address: Telephone No: Postal Code Name of Organzation: PART B – INDIVIDUAL(S) REQUIRING A CRIMINAL RECORD CHECK: Clearly print the names of individuals requring a criminal record check and for whom applications are attached (a list of names is not required for those establishing or replenishing a Draw Down account). Surname First Given Name Middle Name(s) _______________________________ ____________________________ ___________________________ _______________________________ ____________________________ ___________________________ _______________________________ ____________________________ ___________________________ _______________________________ ____________________________ ___________________________ _______________________________ ____________________________ ___________________________ _______________________________ ____________________________ ___________________________ (Year / Month / Day) PSSG 08-000 01/2010 PART C – FOR SECURITY PROGRAMS USE ONLY: Invoice # ______________________________________ Trans # or Approval # ___________________________ Completed by ________ Date _______________ Criminal Records Review Program Application for Pre-Authorized CREDIT CARD USAGE To be completed if paying by credit card. Ministry of Justice Policing and Security Programs Branch Security Programs Division Criminal Records Review Program www.pssg.gov.bc.ca/criminal-records-review Mailing Address: P.O. Box 9217 STN PROV GOVT Victoria, BC V8W 9J1 Tel:1-855-587-0185Fax:(250) 356-1889 (Month / Year)...

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