Offence Declaration Form

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1270 Pembroke Street West, Pembroke ON K8A 4G4
t. 613.735.0151
|
f. 613.735.6315 |
| Twitter: @RCDSB
Offence Declaration
Date of Birth
Name
yyyy
mm
dd
Position (Job Title)
Location
Employee No
I DECLARE that: (check one)
I have no convictions under the Criminal Code of Canada up to and including the date of this
declaration for which a pardon has not been issued or granted under the Criminal Records Act (Canada).
OR
I have the following convictions for offences under the Criminal Code of Canada for which a pardon
under the Criminal Records Act (Canada) 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 _________________/20 ____ .
(Town, City, Etc)
Signature

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