HOUSE TO HOUSE COLLECTION ACT 1939 DECLARATION Surname all Forenames Maiden name Previous Surnames Present address Post code Age Telephone number Date of Birth Place of Birth Sex M/F HAVE YOU BEEN CONVICTED FOR ANY OFFENCE SHOWN BELOW WHICH IS NOT NOW 'SPENT' UNDER THE TERMS OF THE REHABILITATION OF OFFENDERS ACT 1974 (see table overleaf) OR HAD A FORMAL CAUTION RECORDED AGAINST YOU WITHIN THE LAST THREE YEARS FOR ANY OFFENCE SHOWN BELOW. Offences under section 47 to 56 of the Offences against the Persons Act 1861; Robbery, Burglary, Blackmail under the Theft Act 1968; Offences in Scotland involving personal violence or lewd, indecent or libidinous conduct, or dishonest appropriation of property; Offences under the Street Collections Regulation (Scotland) Act 1915; Offences under section 5 of the Police, Factories, etc (Miscellaneous Provisions) Act 1916. If yes provide details below including date, offence and the court or body which dealt with you. If you knowingly or recklessly make a statement false in a material particular you will be liable to a fine not exceeding level 3 on the standard scale or imprisonment for a term not exceeding 6 months or both. If you fail to provide details as requested then your application may be refused. Date of conviction/ Caution (Including Police Force) Offence Sentence (including suspended sentences) If no convictions or cautions enter NIL Date…………………….…………………….. Signed…………………………………………………. SEE OVER REHABILITATION OF OFFENDERS ACT 1974 SENTENCE Absolute Discharge Probation order in respect of persons convicted before 03/02/1995, supervision order conditional discharge or bind over Probation order on or after 03/02/1995 Attendance centre order Hospital order under Mental Health Act BECOMES SPENT AFTER 6 months 1 year from date of conviction or until order expires whichever is later 5 years 1 year after expiry 5 years from date conviction or 2 years after order expires SENTENCE Imprisonment (including suspended sentence) of between 6 months and 2 ½ years (including cashiering, dismissal with disgrace, discharge with ignominy from Armed Forces) Imprisonment (including suspended sentence) of up to 6 months (includes dismissal from Armed Forces and Borstal Training) Fine or other sentence not otherwise covered in this table e.g. CSO Curfew Detention under S53 Children & Young Persons Act between 6 and 30 months Detention of less than 6 months under the above provisions N.B. A sentence of more than 2 ½ years can never become spent. Halve above if under 18 when convicted. BECOMES SPENT AFTER 10 years 7 years 5 years 5 years 3 years