FORM 44 (Section 667)
I, (name), a fingerprint examiner designated as such for the purposes of section 667 of the Criminal Code by the Minister of Public Safety and Emergency Preparedness, do hereby certify that (name) also known as (aliases if any), FPS Number , whose fingerprints are shown reproduced below (reproduction of fingerprints) or attached hereto, has been convicted, discharged under section 730 of the Criminal Code or convicted and sentenced in Canada as follows:
(record)
Dated this day of A.D. , at
Fingerprint Examiner