E-mail: crcefax@ca.ibm.

com
BackCheck Zero-In External
IBM Representative:
UDN/Function:
Phone:

3. Service Menu please
services requested

BackCheck Zero-In
Consent for Disclosure of Personal Information
Declaration of Offences
To ensure accuracy, you must PRINT in clear CAPITAL letters and complete this form in its entirety.
PLEASE NOTE: The following information is required in order to accurately complete a name based criminal record check. List all offences in as much
detail as possible to ensure an accurate disclosure. This name based criminal record check will be completed based on information previously provided to
BackCheck and IBM Canada Ltd..
This form must be submitted within 30 days of the initial request.
Gender: Check One

Middle Name(s):

Given Name(s):

Male
Surname:

Female

Maiden name:

Aliases, nicknames and any other names:

Place of Birth:

Date of Birth:
City

Province

Country

yyyy

mm

dd

I certify that the information in this Disclosure for Personal Information is true and correct to the best of my ability.
Have you been convicted of a criminal offence for which a pardon has not been granted?
Yes
No
Have you been granted a conditional discharge within the past three (3) years?

Yes

No

Have you been granted an absolute discharge within the past year?

Declaration of Offences

Yes
No
If you have answered Yes to any of the above questions, please provide details on ALL convictions/discharges (attach additional pages if required):
Offence: a violation or breach of a law listed in the Criminal Code of Canada (examples: Driving Under Influence, Assault, Theft, Fraud, etc)
Date: Please provide the year and month of your conviction/discharge.
Location: Please provide the location (City and Province) of the conviction/discharge.
Penalty: Please describe the sentencing (examples: The fine amount, jail term, license suspension, probation, etc).
Offence
Date (yyyy/mm)
Location (City/Province)
Penalty

/
/
/
/
Disclaimer: The existence of a conviction will not preclude you from consideration for employment with IBM Canada Ltd.. Details of the offence are
requested to enable IBM Canada Ltd. to determine whether the offence is related to your employment or intended employment.
Date: (yyyy/mm/dd)

Candidate Signature:
Confirming Accuracy of Above Declaration of Offences

12/29/11

The content above is strictly confidential. If you have received this in error, please call 1-877-308-4663 immediately. Thank you for your cooperation. #

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