Conviction self-declaration

ACCORD Hospice ACCORD Hospice: Morton Avenue PAISLEY PA2 7BW Registered Charity No. SC013682 August 2015 Volunteer Application Form (Page 3) Criminal Conviction Self Declaration We ask all volunteers with us to give us information of previous convictions. Having a previous conviction does not automatically bar you from volunteering with us, but it will help us, in discussion with you, decide if the opportunity you have applied for is the most suitable. All information given here will be kept in your personal file which can only be accessed by authorised staff. Under the terms of the Rehabilitation of Offenders Act 1974, you are entitled to withhold information about any convictions against you with are now ‘spent’. You may only withhold information on ‘spent’ convictions. Please ask us if you need any help completing this section of the form and we will be happy to assist you. Conviction Date Offence Occurred Criminal Convictions Pending I declare that, to the best of my knowledge, the above information is correct. I understand that if I take up a volunteer opportunity and it is found that I have deliberately given false information or withheld relevant information, then the opportunity may be withdrawn. Have you ever been convicted of a criminal offence, been bound over or cautioned or are currently the subject of proceedings which might lead to a conviction, an order binding you over or a caution, in the UK or any other country?*