CRIMINAL RECORD DECLARATION FORM

As part of the role of an Approved 10 (Independent Operator) Employee, under the SERMI UK Scheme, you will be granted access to vehicle security-related information from vehicle manufactures.

Under section 6.3.4 of the "Scheme for accreditation, approval and authorisation to Access Security-related Repair and Maintenance Information (RMI) (published by the SERMI operations group in February 2023) you need to meet the criteria listed in point 4.3.4 of Appendix 3 of Annex x to the Regulation (EU) 2018/858. Criteria 4.3.4b states that the Conformity Assessment Body (CAB) 'shall verify that the employee has a clean criminal record. In order for RMISC (RMI Standards and Certification), acting as the CAB, to verify you have a clean criminal record we require a 'Basic' DBS (Disclosure Barring Service) certificate dated within 6 months of the 10 Employee application form submission and completion of this Criminal Record Declaration Form.

Please complete this form and return it to us with your 'Basic' DBS certificate and your I0 Employee application form.

Name

TitleFirst Name(s)Surname

Email Address

Please complete if you would like a copy of the submitted form emailing to you.

Have you ever been convicted by the courts or cautioned, reprimanded or given a final warning by the police? (please include all ‘spent’ convictions)

If yes, please provide details of the offence(s), penalties and dates below.

Please complete the above with as much detail as possible before signing and dating the declaration below.

I confirm that the information contained within this form is accurate and correct.

Signature

Date

Print Name