Declaration of Criminal Record

To be completed by Applicant

This form must be completed in order to receive a copy of the Criminal Convictions and Associated
Information from the RCMP National Repository of Criminal Records

Surname Given Name Gender Date of Birth (yyyy-mm-dd)

Male Female
Current Address City Province Postal Code

DECLARATION OF CRIMINAL RECORD

 Does not constitute a Certified Criminal Record by the RCMP

 May not contain all criminal record convictions

DO NOT DECLARE:

 Any charges for which you have received a Pardon, pursuant to the Criminal Records Act.
 Any charges for which you were not convicted, for example, charges that were withdrawn or
dismissed.
 Any Provincial or Municipal offences
NOTE: A Certified Criminal Record can only be issued based on the submission of fingerprints to the
RCMP National Repository of Criminal Records

OFFENCE DATE OF SENTENCE LOCATION CITY OF

COURTHOUSE

Applicant’s Signature Date

PERSONAL INFORMATION ON THIS FORM IS COLLECTED AND DISCLOSED UNDER THE AUTHORITY OF THE POLICE SERVICES ACT AND WILL BE USED TO DISCLOSE
PERSONAL INFORMATION TO THE PERSONS OR AGENCIES SO DESIGNATED. QUESTIONS SHOULD BE DIRECTED TO: GENERAL MANAGER. CCR BUSINESS INFORMATION
LIMITED. 251 Consumers Road, Suite 401, Toronto, ON M2J 4R3, TEL. (416) 499-9936, FAX (416) 499-9703.