Staff & Board Member Offence Declaration Form

I DECLARE, since the last Criminal Records Check provided to Big Brothers Big Sisters of Waterloo Region (BBBSWR), or since the last Offence Declaration Form submitted to BBBSWR, that:

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 select the appropriate statement:

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 the Chief Executive Officer at the time of the occurrence(s).

I hereby attest that the information disclosed herein is true, complete and accurate to the best of my knowledge and belief. I understand that failure to complete an accurate and truthful Offence Declaration will lead to a review of my continued service with BBBSWR.

Your Name

First Last

Witness Name

First Last

Date