Form No. 1 (page 1 of 5)

SECTION A - PERSONAL INFORMATION

Name

Alias or Former Name

Address

Date of Birth

RCMP Automated Fingerprint Indentication System No. (if any)

Type of Conviction (Summary or Indictable or Finding of Dangerous Offender or Long-Term Offender

In Custody Not In Custody

Person Making Application on Applicant's Behalf (if any)

Repesentative's Address

Telephone Number