Offence Declaration Form

I DECLARE, since the last Criminal Records Check provided to Big Brothers Big Sisters of London and Area, or since the last Offence Declaration Form submitted to Big Brothers Big Sisters of London and Area, that(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 or restricted for any reason

Please check the appropriate line:(Required)

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

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

Date(Required)

Name(Required)

First Last

Signature(Required)

Witness(Required)

First Last

SMS Verification(Required)