Annual Declaration with Respect to Criminal Charges and/or Criminal Record
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Are You?
Lay Member of a Community of Faith performing Marriages
Licensed Lay Worship Leader
Sacraments Elder
Lay Person
Community of Faith
Name of Community of Faith
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of last Police Record Check
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
level 2 vulnerable sector check not older than 6 years
Charges or Convictions: I have had no criminal charges or 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 had no charges
I have had charges (please specify below)
Please specify the charge(s)or conviction(s):
*
Disclaimer: By submitting this form I hereby declare that the information provided on this form is accurate as of the date of submission. This requirement to file a form annually does not in any way override or replace the requirements for reporting included in Section J.10 of The Manual. Providing false or misleading information may result in discipline, loss of position or loss of employment.
Submit
Should be Empty: