CRIMINAL RECORD STATEMENT 117

VARIETY CHILDREN & FAMILY SERVICES INC

CRIMINAL RECORD STATEMENT

Child Protection Laws of Sierra Leone require all persons associated with children facilities to be finger printed, have a police clearance and disclose any criminal conviction. A police clearance will disclose any criminal history you may have.

I declare under penalty of perjury under the laws of Sierra Leone that I have read and understand the information contained in this affidavit and that my responses and any accompanying attachment are true and correct.

CRIMINAL RECORD STATEMENT

HAVE YOU EVER BEEN CONVICTED OF A CRIME ?

YES

If you answered YES , attach a signed statement indicating the nature and circumstances of the crime, the date and location in which it occurred. If you answered NO and you are wrong, your answer will be considered as not true and it will be held against you in a court of law. YOU MUST DISCLOSE CONVICTIONS no matter how long ago or whether it was a minor or major crime or whether you went to court or not or whether you went to jail/prison or not.

Agency Name:

Address:

Applicant Name:

First

Last

Address:

National ID/Drivers Lic:

Signature:

Date of Birth:

Phone Number:

Date:

©VCFS0039/14

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