BSF697 - Personnel Screening, Consent and Authorization Form

Office Use Only

• Reference number
• Department/Organization number
• File number

A. Administrative Information (To be completed by the Authorized Departmental/Agency/Organizational Official)

• Status of Request
  • New
  • Update
  • Upgrade
  • Transfer
  • Supplemental
  • Re-activation
    
• The requested level of reliability/security check(s)
  • Reliability Status
  • Level I (Confidential)
  • Level II (Secret)
  • Level III (Top Secret)
  • Other
• Particulars of Appointment/Assignment/Contract
  • Indeterminate
  • Term
  • Contract
  • Industry
  • Other (specify secondment, assignment, etc.)
• Justification for security screening requirement
• Position/Competition/Contract number
• Title
• Group/Level (Rank if applicable)
• Employee ID number/PRI/Rank and Service number (if applicable)
• If term or contract, indicate duration period (From/To)
• Name and address of department / organization / agency
• Name of official
• Telephone number
• Facsimile number

B. Biographical Information (to be completed by the applicant)

• Surname (Last Name)
• Full given names (no initials) underline or circle usual name used
• Family name at birth
• All other names used (i.e. Nickname)
• Sex (Male/Female)
• Date of birth (Year/Month/Day)
• Country of birth
• Date of entry into Canada if born outside Canada (Year/Month/Day)
• Daytime telephone number
• E-mail address
• Residence (provide addresses for the last five years, starting with the most current)
  • Home address
    • Residence 1
      • Apartment number
      • Street number
      • Street name
      • Civic number (if applicable)
      • City
      • Province or state
      • Postal Code
      • Country
      • Telephone number
      • From (Year/Month)
      • To: Present
    • Residence 2
      • Apartment number
      • Street number
      • Street name
      • Civic number (if applicable)
      • City
      • Province or state
      • Postal Code
      • Country
      • Telephone number
      • From (Year/Month)
      • To (Year/Month)
• Have you previously completed a Government of Canada security screening form? (Yes/No )
  • If yes, give name of employer, level and year of screening.
    • Name of employer
    • Level
    • Year
• Criminal Convictions In and Outside of Canada (see instructions)
  • Have you ever been convicted of a criminal offence for which you have not
    been granted a pardon? (Yes/No)
    • If yes, give details.
      • Charge(s)
      • Name of police force
      • City
      • Province/State
      • Country
      • Date of conviction (Year/Month/Day)

C. Consent and Verification (To be completed by the applicant and authorized Departmental/Agency/Organizational Official)

1. Date of birth, address, education, professional qualifications, employment history, personal character references
   • Applicant's initials
   • Name of official (print)
   • Official's initials
   • Official's Telephone number
2. Criminal record check
   • Applicant's initials
   • Name of official (print)
   • Official's initials
   • Official's Telephone number
3. Credit check (financial assessment, including credit records check)
   • Applicant's initials
   • Name of official (print)
   • Official's initials
   • Official's Telephone number
4. Loyalty (security assessment only)
   • Applicant's initials
5. Verification of Databases with Customs, Immigration and Police Information
   • Applicant's initials
   • Name of official (print)
   • Official's initials
   • Official's Telephone number

The Privacy Act Statement

The information on this form is required for the purpose of providing a security screening assessment. It is collected under the authority of subsection 7(1) of the Financial Administration Act and the Policy on Government Security (PGS) of the Government of Canada, and is protected by the provisions of the Privacy Act in institutions that are covered by the Privacy Act. Its collection is mandatory. A refusal to provide information will lead to a review of whether the person is eligible to hold the position or perform the contract that is associated with this Personnel Screening Request. Depending on the level of security screening required, the information collected by the government institution may be disclosed to the Royal Canadian Mounted Police (RCMP) and the Canadian Security Intelligence Service (CSIS), which conduct the requisite checks and/or investigation in accordance with the GSP and to entities outside the federal government (e.g. credit bureaus). It is used to support decisions on individuals working or applying to work through appointment, assignment or contract, transfers or promotions. It may also be used in the context of updating, or reviewing for cause, the reliability status, security clearance or site access, all of which may lead to a re-assessment of the applicable type of security screening. Information collected by the government institution, and information gathered from the requisite checks and/or investigation, may be used to support decisions, which may lead to discipline and/or termination of employment or contractual agreements. The personal information collected is described in Standard PIB PSU 917 (Personnel Security Screening) which is used by all government agencies, except the Department of National Defence PIB DND/PPE 834 (Personnel Security Investigation File), RCMP PIB CMP PPU 065 (Security/Reliability Screening Records), CSIS PIB SIS PPE 815 (Employee Security), and PWGSC PIB PWGSC PPU 015 (Personnel Clearance and Reliability Records) used for Canadian Industry Personnel. Personal information related to security assessments is also described in the CSIS PIB SIS PPU 005 (Security Assessments/Advice).

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 I no longer require a reliability status, a security clearance or a site access clearance, my employment or contract is terminated, or until I otherwise revoke my consent, in writing, to the authorized security official.

• Signature (hand signature only)
• Date (Year/Month/Day)

D. Review (To be completed by the authorized Departmental/Agency/Organizational Official responsible for ensuring the completion of sections A, B and C)

• Name
• Title
• Telephone number
• Address
• Facsimile number

E. Approval (To be completed by authorized Departmental/Agency/Organizational Security Official only)

I, the undersigned, as the authorized security official, do hereby approve the following level of screening.

• Reliability Status
  • Approved Reliability Status / Not approved
  • Name
  • Title
  • Signature (hand signature only)
  • Date (Year/Month/Day)
• Security Clearance (if applicable)
  • Level I / Level II / Level III / Not recommended
  • Name
  • Title
  • Signature (hand signature only)
  • Date (Year/Month/Day)
• Comments
• Photo (for Level III T.S., and/or upon request - see instructions)

Instructions for Personnel Screening Consent and Authorization Form TBS/SCT 330-23E (Rev. 2002/02)

Once completed, this form shall be safeguarded and handled at the level of Protected A.

General:

If space allotted in any portion is insufficient please use separate sheet using same format.

1. Section A (Administrative Information) Authorized Departmental/Agency/Organizational Official

The Official, based on instructions issued by the Departmental Security Officer, may be responsible for determining, based on five year background history, what constitutes sufficient verification of personal data, educational and professional qualifications, and employment history. References are to be limited to those provided on the application for employment or equivalent forms.

Supplemental Information Requirements

Persons who presently hold a Security Clearance and subsequently marry, remarry or commence a common-law partnership, in addition to having to update sections of the Security Clearance Form (TBS/SCT 330-60), are required to submit an original Personnel Screening, Consent and Authorization Form, with the following parts completed:

• Part A - As set forth in each question
• Part B - As set forth in each question, excluding criminal convictions in and outside of Canada.
• Part C - Applicant's signature and date only are required

"Other". This should be used to identify if the security screening is for Site Access, NATO, SIGINT etc.

2. Section B (Biographical Information)

To be completed by the applicant. If more space is required use a separate sheet of paper. Each sheet must be signed.

Country of Birth - For "NEW" requests, if born abroad of Canadian parents, please provide a copy of your Certificate of Registration of Birth Abroad. If you arrived in Canada less than five years ago, provide a copy of the Immigration Visa, Record of Landing document or a copy of passport.

• List only criminal convictions for which a pardon has NOT been granted. Include on a separate attached sheet of paper, if more than one conviction. Applicant must include those convictions outside Canada.
• Offences under the National Defence Act are to be included as well as convictions by courts-martial are to be recorded.

3. Section C (Consent and Verification)

A copy of Section "C" may be released to institutions to provide acknowledgement of consent.

Criminal record checks (fingerprints may be required) and credit checks are to be arranged through the Departmental Security Office or the delegated Officer.

Consent: may be given only by an applicant who has reached the age of majority, otherwise, the signature of a parent or guardian is mandatory.

The age of majority is:

• 19 years in NFLD., N.S., N.B., B.C., Yukon, Northwest Territories and Nunavut;
• 18 years in P.E.I., Que., Ont., Man., Sask. and Alta.

The applicant will provide initials in the "applicant's initials box".

The official who carried out the verification of the information will print their name, insert their initials and telephone number in the required space.

• Reliability Screening (for all types of screening identified within Section A): complete numbers 1 and 2 and 3 if applicable.
• Security Clearance (for all types of screening identified within Section A): complete numbers 1 to 4 and 5 where applicable.
• Other: number 5 is used only where prior Treasury Board of Canada Secretariat approval has been obtained.

4. Section D (Review)

To be completed by authorized Departmental/Agency/Organizational Official who is responsible for ensuring the completion of sections A to C as requested.

5. Section E (Approval)

Authorized Departmental/Agency/Organizational Security Official refers to the individuals as determined by departments, agencies, and organizations that may verify reliability information and/or approve/not approve reliability status and/or security clearances. Approved Reliability Status and Level I, II and III, as well as the signature of the authorized security official or manager are added for Government of Canada use only. Applicants are to be briefed, acknowledge, and be provided with a copy of the "Security Screening Certificate and Briefing Form (TBS/SCT 330-47)".

Note: Private sector organizations do not have the authority to approve any level of security screening.

Photographs: Departments/Agencies/Organizations are responsible for ensuring that three colour photographs of passport size are attached to the form for the investigating agency. Maximum dimensions are 50mm x 70mm and minimum are 43mm x 54mm. The face length from chin to crown of head must be between 25mm x 35mm. The photographs must be signed by the applicant and an authorized security official. The photographs must have been taken within the last six months. It is required for new or upgrade Level III security clearances for identification of the applicant during the security screening investigation by the investigating agency. The investigating agency may in specific incidents request a photograph for a Level I or II clearances when an investigation is required.

Date modified:

2012-11-30