ANNUAL CRIMINAL OFFENCE DECLARATION
Please select one of the following: I declare, that; ● Up to and including the date of this declaration, I have no convictions under the Criminal Code (Canada) for which a pardon has not been granted under the Criminal Records Act (Canada), and/or any other offences.
OR ● Up to and including the date of this declaration, I have the following convictions for offences under the Criminal Code (Canada) for which a pardon under the Criminal Records Act (Canada) has not been granted, and/or the following offences. Date of Offence: ______________________ Charge/Offence: ________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Location/Jurisdiction: ____________________________________________________ Penalty/Conviction: ______________________________________________________ ________________________________________________________________________ ________________________________________________________________________
Name: __________________________________ Signature: _______________________________ Date: _______________________________