Statutory Declaration Form

Annual Statutory Declaration Form

Please provide the following information:


Today's Date:












Confirmation For Police Criminal Record Check

I,, Director/Board Member, Pembroke/Renfrew County Crime Stoppers, do swear that my Police Criminal Record Check is up-to-date according to the Pembroke/Renfrew County Crime Stoppers Board Members Policy.

Yes, I agree











Oath of Secrecy

I,, Director/Board Member, Pembroke/Renfrew County Crime Stoppers, do swear that I will faithfully protect the confidential sanctity of all and any Crime Stoppers information that may become known to me in any form by virtue of my position with Pembroke/Renfrew County Crime Stoppers and I swear I will not disclose, communicate or convey or allow to be disclosed, communicated or conveyed, directly or indirectly, to any person any such confidential information in any manner and I swear that I will maintain, participate and engage my duties faithfully and honestly to serve Pembroke/Renfrew County Crime Stoppers and my community with the integrity and professionalism that would be expected of me.

Yes, I agree