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Printable Application

Directions:

1) Enter the required information (*) or print the application and fill it in by hand.

2) Print a copy of the completed application (keep one for your records).

3) Fax the application to: 780-665-7371, mail it in with your cheque or money order, or bring it to your appointment.

________________________________________________________________________________________________

* 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: * 2nd Preferred Method:

* 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, Povince and Country of Birth

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

* Citizenship (you must be a Canadian Citizen to get a U.S. Waiver through our office, and the same goes for Indictable Offense Pardons)

*If you are applying for a Pardon or a 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:

 Canadian Pardon: $795.00 plus GST ($39.75) = $834.75. Note: When your application is ready to be submitted you will be required to pay the Parole Board Filing Fee, which is now $631.00 (as of February 23, 2012). Note: Does not include $84.00 Biometric Fingerprinting Fee. Note: Additional Court Record Search fees will apply if you have offenses where fines were imposed. Additional fees will also apply if you have served in the Canadian Military, and for each Local Police Records Check from where you have lived for last 5 years. Court Record and Military Record Searches are $84.00 each, and Local Police Record Checks are $35.00, including GST, plus the Police Agency Fee (if applicable). For more information please see our Prices page.

 US Entry Waiver: $695.00 plus GST ($34.75) = $729.75. (Does not include our $84.00 Biometric Fingerprinting Fee or Court Record Searches, which if required are normally $84.00 each) 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 (as of November 23, 2010). Note: If you have a Sexual Assault conviction we may also need to do 1 or 2 Privacy Act Information Requests for $252.00 each. For more information please see our Prices page.

 Canadian Pardon and U.S. Entry Waiver: $1490.00 plus GST ($74.50) = $1564.50. (Does not include Court Record Searches or Local Police Records Checks. Does not include $168.00 Biometric Fingerprinting Fee or the $631.00 Parole Board Filing Fee or the $585.00 USD Department of State Filling Fee.)

Priority Service Fee: $126.00. *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 this fee will apply. For more information please see FAQ Pardons Page, # 5.

Pardoned Record and/or Court Record Search only: $189.00. For more information please see our Prices page.

Port of Entry Parole (for emergency travel into the U.S.): $252.00. 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. (For more information please see our Prices page or our Pardon FAQ's)

Privacy Act Information Request: $252.00. For more information please see our Prices page.

US Entry Waiver Renewal (only for past Alberta Pardons clients) $595.00 plus GST = $624.75

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* Credit Card Information  (we also accept cash, cheques, money orders or debit cards)

MasterCard or Visa Number

Expiry Date / MM/YY

CVV Number

Name on Card   Note: Your credit card will show "ALBERTAPARD-ABFPS"

 

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 $83.00 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. Entry 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)? 

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 Waivers an additional $729.75 fee and for Pardons an additional $834.75 fee will apply an 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)

Please print this form and then mail, fax or bring it in. (Click on "File" then "Print")

Alberta Pardons
Office Address: 205, 12907 - 97 Street, Edmonton, AB.


Mailing Address
P.O. Box 71111
Edmonton, AB.
T5E 6J8


Fax: 780-665-7371
Ph: 780-473-7171

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