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Form No. 2
Consent to the Release of Personal
Information
Please Print
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I,
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[name],
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of
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[city, town, municipality],
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in the Province of
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,
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was convicted for
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[name of offence]
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in relation to
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[specifics of offence]
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on
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[date of conviction].
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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.
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Applicant's Signature
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Date
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Witness's Signature
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Date
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Full Name of Witness
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Province
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