Application Form

Directions:

1) Enter the required information (*).

2) Print the completed application (for your records).

3) Submit the application or press Enter on your keyboard.

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* Full Name * Other Names	(your Full Legal Currently Used Name) (maiden name, previous married name(s), legal name changes, documented nick names, names stated to authorities)
* Mailing Address
Physical Address	(needed if mailing address is different or is a PO Box #)
* City * Province and Country * Postal Code * How long have you lived at this address?	(month & year you moved in)
* Home Phone Cell Phone
* Work Phone * Present Employer	I am Self-Employed. I need to enter the U.S. for business. (Kept Confidential)
* Private Email	(No Hotmail Please) Get Free Gmail

* 1st Preferred Method of Contact: Home phone Mail E-mail Work phone Cell phone Fax * 2nd Preferred Method: Home phone Mail E-mail Work phone Cell phone Fax

* Are members of your household aware of this application?

Yes

No

Married/Common Law

Single

Separated

		(i.e. March 14, 1970)
* Date of Birth
* Male	Female

* City, Province and Country of Birth

* Driver's Lic. # and Province (i.e. 55-555-555 Alberta)

*If you are applying for a Pardon or Waiver, please write all the Additional Addresses of where you have lived in the last 5 or 10 years in the boxes below. If you are applying for a Pardon it's 10 years, and there will be an additional $33.33 plus GST = $35.00 Admin Fee plus Police Agency Fee (if applicable) to cover Local Police Record Searches for each additional city/town you have lived in, within the last 5 years. Multiple charges will not apply if the same police agency serves each location. For Waiver applications it's 5 years and there are no additional charges.

1. , From: (MM YY) To: (MM YY) * ( PO Box Numbers are not accepted by the PBC )

2. , From: (MM YY) To: (MM YY) ( Postal Codes are NOT required )

3. , From: (MM YY) To: (MM YY)

4. , From: (MM YY) To: (MM YY)

5. , From: (MM YY) To: (MM YY)

6. , From: (MM YY) To: (MM YY)

7. , From: (MM YY) To: (MM YY)

* Service(s) Required:

 Premium US Entry Waiver: $695.00 plus GST ($34.75) = $729.75. Note: When your application is ready to be submitted to US Customs you will be required to pay a $585.00 (USD) United States Department of State filing fee. Does not include a Biometric Fingerprinting Fee. Note: Court Record Searches (not required for all offenses) are normally $84.00 from Alberta. For more information please see our Fees page. 

Please Note: If you have a Sexual Assault conviction there will be higher fees due to increased paperwork. For more information please see our Fees page.

 Premium Canadian Pardon and U.S. Entry Waiver: $1295.00 plus GST = $1359.75. (Does not include Court Record Searches or Local Police Records Checks. Does not include a Biometric Fingerprinting Fee, or the $657.77 Parole Board Filing Fee, or the $585.00 USD Department of State Filling Fee.)

Priority Service Fee: $120.00 per half hour, plus GST. *NOTE: We prioritize all applications at no extra cost, however, in some cases where staff must work overtime in order to meet a last minute deadline, or all documents are to be sent by courier, this fee will apply. For more information please see FAQ Pardons Page, # 5.

Pardoned Record and/or Court Record Search only: $189.00, includes GST. For more information please see our Fees page.

Port of Entry Parole (for emergency travel into the U.S.): $252.00, includes GST. Note: This permit is for clients who are applying for a Standard US Entry Waiver, and who need to enter the United States for emergency life-saving medical treatment or to attend a funeral for an immediate family member ONLY. Please call our office or see our Waiver FAQ section (10 & 14) if you are unsure if you are eligible to receive such a permit.

Police File Destruction Services: $519.75, includes GST. (For more information please see our Fees page or our Pardon FAQ's)

Privacy Act Information Request: $252.00, includes GST. For more information please see our Fees page.

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* Credit Card Information

MasterCard or Visa Number

Expiry Date / MM/YY

CVV Number

Name on Card

 

Please bill in 2, 3 or 4 monthly installments. Please Note: Your credit card will be billed in 3 monthly installments for Pardons, 2 for Waivers, and 4 installments for both. An additional $10.50 processing fee will apply.

* Have you ever served in the Military?

Yes (For Pardons there is a $84.00 charge to cover Military Record Search fees) Note: In the Comments Section below please provide your Military ID Number, Service Dates, Address of Unit, and the Name of your Commander.

No

* Have you received a Pardon in the past?

Yes

No

* Have you ever applied for a U.S. Waiver in the past?

Yes (If YES enter your A-Number, Date & Location Filed or Date and Time Period Granted)

No

* Have you ever been questioned by U.S. Customs about your criminal record, or denied entry into the U.S. because of your record?

Yes (If YES when & where were you questioned & were you denied entry) I was denied entry.

No

* Do you have a Passport? (Note: Since August of 2008 Passports have been encoded with an FPS (FingerPrint Service) number if you have a criminal record on CPIC at the time your Passport is processed.)

Yes (Year obtained or renewed)

No

* When were you charged or convicted of the offense(s)?  Less than 1 year ago 1 - 3 years ago 3 - 5 years ago More than 5 years ago More than 10 years ago More than 15 years ago Multiple offenses in last 5 years Multiple offenses over 5 years ago Multiple offenses over 10 years ago Multiple offenses over 15 years ago Please Select

* Do you have any Assault CBH or Assault with a Weapon convictions?  

Yes  (For Pardons an additional $252.00 fee will apply for a Privacy Act Information Search in order to obtain the age of the victim and any injuries)

No

* Do you have any Sexual Assault convictions?  

Yes  (For Pardons and Waivers an additional $504.00 fee will apply per service due to the much higher work load for these types of offenses) 

No

Comments: (Please include your convictions [if known] and the locations [city or town] of where you were sentenced)

For your records please print this form before submitting it. (Click on "File" then "Print")

  Note: Your credit card will show "ALBERTAPARD-ABFPS"