Criminal Offence Declaration Form
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1CRIMINAL OFFENCE DECLARATION FORM
NAME:
DATE OF BIRTH: YY/MM/DD
POSITION:
LOCATION/SCHOOL
1. I DECLARE, since the last Criminal Reference Check (CRC) provided to Nova Central
School District, or since the last Criminal Offence Declaration (COD) given by me to the
district, that:
Criminal Code of Canada
a. I have no convictions under the
up to and including the
date of this declaration for which a pardon has not been issued or granted under
Criminal Records Act (Canada)
the
.
b.
Criminal Code of Canada
I have no charges pending under the
up to and
including the date of this declaration.
OR
Criminal Code of Canada
2. I have the following convictions for offences under the
for
Criminal Records Act (Canada)
which a pardon under the
has not been issued or
granted.
List of Offences
1)
a.
Date:
_________________________________________
b.
Court Location:
_________________________________________
c.
Conviction:
_________________________________________
2)
a.
Date:
_________________________________________
b.
Court Location:
_________________________________________
c.
Conviction:
_________________________________________
3)
a.
Date:
_________________________________________
b.
Court Location:
_________________________________________
c.
Conviction:
_________________________________________
(Use additional page if necessary)
DATED at ___________________________this _____ day of ________________, __________.
________________________________________
Signature
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Parent category: Financial