Annual Offence Declaration Form

I DECLARE, since the last Criminal Records Check (Includes a Vulnerable Sector Check for those who are in a position of trust) provided to Big Brothers Big Sisters of London and Area, or since the last Annual Offence Declaration Form submitted to Big Brothers Big Sisters of London and Area, that (check all boxes that apply):(Required)

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 no pardons related to sexually based offences up to and including the date of this declaration under the Criminal Records Act (Canada)

I have no charges pending under the Criminal Code of Canada up to and including the date of this declaration

I have not been the subject of any criminal investigation or allegation, any child welfare investigation or allegation, nor have I had any charges brought against me, even if the charges are pending

My driver’s license has not been suspended, restricted or revoked for any reason

Please check the appropriate line:(Required)

There have been no occurrences as described above since my last Criminal Record Check or submission of an Annual Offence Declaration Form.

All reportable matters as described above were discussed with Agency Staff and/or the Executive Director at the time of the occurrence(s).

Date(Required)

Name(Required)

First Last

Signature(Required)

SMS Verification(Required)