TAG – Self Declaration Form

TAG – Self Declaration FormDave Cairney2024-07-11T17:29:09+00:00

APEX Pre-Employment Screening Services

CRIMINAL RECORD VERIFICATION

Self Declaration Form

CONSENT TO DISCLOSURE OF PERSONAL INFORMATION

DECLARATION OF CRIMINAL RECORD INFORMATION

APPLICANT MUST DECLARE ALL CONVICTIONS FOR OFFENCES UNDER FEDERAL LAW

Printed Name of Applicant (Required)

Self Declaration

I do not have a Criminal Record
Yes I have a criminal record, and I will list offences below

Signature of Applicant - * Please ensure your signature matches the one on the ID provided *

* If necessary you can click the "X" in the upper right hand corner of the box to reset the field and start over *

Date Signed

Signature of Police Personnel:

CONVICTION DATE (1)

OFFENCE (and POLICE SERVICE if known)

LOCATION OF OFFENCE

CONVICTION DATE (2)

OFFENCE (and POLICE SERVICE if known)

LOCATION OF OFFENCE

CONVICTION DATE (3)

OFFENCE (and POLICE SERVICE if known)

LOCATION OF OFFENCE

CONVICTION DATE (4)

OFFENCE (and POLICE SERVICE if known)

LOCATION OF OFFENCE

CONVICTION DATE (5)

OFFENCE (and POLICE SERVICE if known)

LOCATION OF OFFENCE

CONVICTION DATE (6)

OFFENCE (and POLICE SERVICE if known)

LOCATION OF OFFENCE

CONVICTION DATE (7)

OFFENCE (and POLICE SERVICE if known)

LOCATION OF OFFENCE

CONVICTION DATE (8)

OFFENCE (and POLICE SERVICE if known)

LOCATION OF OFFENCE

CONVICTION DATE (9)

OFFENCE (and POLICE SERVICE if known)

LOCATION OF OFFENCE

CONVICTION DATE (10)

OFFENCE (and POLICE SERVICE if known)

LOCATION OF OFFENCE

DO NOT LIST ANY OF THE FOLLOWING OFFENCES ON THIS FORM:

Conviction for which the applicant has received a Record Suspension (Pardon) in accordance with the Criminal Records Act;

"Findings of Guilt" where the applicant was a "young person" under the Youth Criminal Justice Act;
(unless there are also adult convictions)

Absolute Discharges or Conditional Discharges, pursuant to Section 730 of the Criminal Code;

Offences for which the applicant was not convicted
Any provincial or municipal offence, and;

Any charges dealt with outside of Canada

This Declaration of Criminal Record Information does not constitute a Certified Criminal Record by the RCMP.

This Declaration of Criminal Record Information may not contain all criminal record convictions

A Certified Criminal Record can only be issued by CCRTIS based on the submission of Fingerprints to the RCMP National Repository of Criminal Records.

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