Offence Declaration Form

Appendix A: Offence Declaration Form

Employee First Name

Employee Last Name

School Year

Offence Declaration

I declare 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).

I have the following convictions for offences under the Criminal Code of Canada for which a pardon under the Criminal Code of Canada Records Act of Canada has not been issued or granted to me.

Number of Offences:

Offence 1: Date / Time

Offence 1: Court Location

Offence 1: Conviction

Offence 2: Date / Time

Offence 2: Court Location

Offence 2: Conviction

Offence 3: Date / Time

Offence 3: Court Location

Offence 3: Conviction

Offence 4: Date / Time

Offence 4: Court Location

Offence 4: Conviction

Offence 5: Date / Time

Offence 5: Court Location

Offence 5: Conviction

Offence 6: Date / Time

Offence 6: Court Location

Offence 6: Conviction

Signature

Sign Here

Date / Time

Offence Declaration Form

Offence Declaration Form

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