Consumer Protection Branch 5775 Yonge Street, Suite 1500 Toronto ON M7A 2E5 Tel.: 416 326-6203 Toll-free: 1 800 889-9768 Fax: 416 326-8810
File Number
Reviewed By Date (yyyy/mm/dd)
It is an offence to make a false statement in this application. In addition to any charges that may be laid, a false statement may delay the processing of this application, and result in its refusal.
Assistant Bailiff, Bailiffs Act Collector, Collection Agencies Act Personal Information Investigator, Consumer Reporting Act Sales Representative, Cemeteries Act (Revised)
New Application Reinstatement Application Renewal Application For Renewal or Reinstatement Give Licence Number
Last Name First Name Middle Name Date of Birth (yyyy/mm/dd)
Male Female
Unit/Suite/Apt. Street Number Street Name PO Box Number City/Town Province Postal Code
Yes No If no, attach valid Employment Authorization document or Landed Immigration document.
Description of activity; i.e. Employment, School, Unemployment Name and Full Address of Employer or Organization
From (yyyy/mm/dd) To (yyyy/mm/dd)
CPB File Number
4. If the answer to any of the following questions is “yes,” attach full details on a separate signed and dated sheet and also attach any relevant documentation.
No Yes. Indicate full details on a separate sheet
No Yes. Indicate type, jurisdiction, registration, licence or appointment number on a separate sheet
No Yes. Indicate type, jurisdiction, registration, licence or appointment number on a separate sheet Previously Reported
No Yes. Indicate full details on a separate sheet Previously Reported
No Yes. Indicate full details on a separate sheet. Previously Reported
I hereby certify that the information provided is, to the best of my knowledge and belief, true.
Dated this day of 20 . Signature of Applicant Print Name in Full
Name of Intended Employer
Unit/Suite/Apt. Street Number Suffix Street Name Street Type Direction P.O. Box Station Rural Route Lot/Part/Block/Section Concession/Plan City/Town/Municipality Province Postal Code
Employer’s Registration Number
I hereby certify that I have personally and fully discussed the response to each question of this application with the applicant prior to executing this document and am satisfied that the information given by the applicant is true to the best of my knowledge and belief, and request that the application be granted. I further certify that I will not employ the applicant in the capacity to which this application applies until I receive his/her certificate of Registration or Licence.
Signature of Authorized Signing Official Print Name and Title in Full
In respect of the Act under which this application is made, I understand that in order to process this application and the information provided in this form, the Consumer Protection Branch, Ministry of Consumer Services, may collect information from, or disclose information to, organizations in or out of Ontario including: licensing or regulatory authorities, government regulators or other law enforcement agencies, the Registrar of Bankruptcies, credit bureaus, professional and industry associations, former or current employers and employers for whom I may be associated with while this licence or registration is valid. Without limiting the generality of the foregoing I understand that the collection/ disclosure may include information from the Canadian Police Information Centre (C.P.I.C.)
I also understand that the information collected pursuant to this application and in relation to the conduct as a licensee or registrant under the Act to which this application is made, may be shared with regulating authorities and/or law enforcement agencies in or out of Ontario and that such information may be used in determining my licence or registration status in all jurisdictions in which I am licensed or registered or have applied to be licensed or registered.
I also understand the Ministry may also use this information for the purpose of conducting quality assurance and other similar programs and may contact me for such a purpose either directly or through an agent.
I understand the Ministry may also disclose to the public by telephone, writing or another manner, including the internet, my registration or licence information including, but not limited to: status, registration, licence number, applicable dates, business name, business contact person, business/ contact address, business/ contact telephone number and business facsimile number, business email address. I further consent to the Ministry disclosing to my current, subsequent and/ or intended employer(s) to which this application pertains of any action taken and of any information gathered in relation to this licence or registration.
I consent to the collection, use and disclosure of this information for the purposes stated above and to determine whether I am and remain qualified for licensing or registration in all jurisdictions.
Dated at this day of 20 . Signature of Applicant Print Name in Full
The public official who can answer questions about the collection of this information is: Ministry of Consumer Services The Consumer Protection Branch 5775 Yonge Street, Suite 1500 Toronto ON M7A 2E5 Telephone: 416 326-6203