BSF684 - CBSA Consent Statement

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Annex to TBS 330-23 Part C #5 - Other

Protected A when completed

I hereby authorize the Canada Border Services Agency (CBSA) to seek, verify, assess, collect and retain any and all information relevant to this application including any criminal records and any and all information contained in law enforcement files, including intelligence gathered for law enforcement purposes, information gathered through CBSA internal databases, and information with respect to my immigration and citizenship status, as well as any and all information that will facilitate the conduct of a security assessment. I also authorize the CBSA to disclose my information to the Royal Canadian Mounted Police (RCMP), Citizenship and Immigration Canada (CIC) as well as entities outside the Federal Government, for verification of its accuracy or for the purposes of carrying out any investigation related to the establishment, confirmation or revocation of any reliability status, security clearance and/or site access to be granted to and maintained by me for employment purposes with the Agency. The information may be used by accredited domestic law enforcement agencies engaged in the administration or enforcement of the law and in the detection, prevention or suppression of a crime.

This personal information will include any and all information I have provided throughout the application and security screening process including but not limited to: given name(s) and any other names used, surname(s) including family name at birth, DOB, sex, marital/common-law/partner information, information on immediate relatives, employment information (including foreign employment), education and activity information, criminal information, citizenship/canadian status information, residency information, travel information, foreign assets, character reference information, military service information, credit information.

The information I provide in this document is collected in accordance with the Financial Administration Act (FAA), the Canada Border Services Agency Act and the Public Service Employment Act for the purposes of granting or reviewing for cause the reliability status, security clearance or site access of individuals working or applying to work through appointment, assignment or contract at the Canada Border Services Agency.

I have read this statement completely and understand that the Canada Border Services Agency will protect my personal information in accordance with the Privacy Act, and that it will only be used to assess and determine my suitability and reliability, and for the security screening related to the application process and the renewal cycle of a security screening level and for any other position within the CBSA to which I may apply. Withholding consent could result in my disqualification from the recruitment or renewal cycle process.

"I, the undersigned, do consent to the disclosure of the preceding information including my photograph for its subsequent verification and/or use in an investigation for the purpose of providing a security screening assessment. By consenting to the above, I acknowledge that the verification and/or use in an investigation of the preceding information may also occur when the reliability status, security clearance or site access are updated or otherwise reviewed for cause under the Policy on Government Security.

My consent will remain valid until such time as any such reliability status, security clearance or site access clearance is no longer a requirement for my continued employment with the Agency, or any successor thereto, my employment is terminated, I am deployed to a position with another employer within the Government of Canada, or I revoke my consent, in writing, to the Director General, Security and Professional Standards of the Agency."

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