Personnel Screening, Consent and Authorization Form

Applicant’s declaration of understanding

I understand that if I provide misleading and/or incomplete information, my security screening application may be denied or the security screening process may be cancelled.

I understand that if it is determined that I provided incorrect information or withheld information on this application form, my reliability status and/or security clearance may be denied or a review for cause of my reliability status and/or security clearance may be initiated. A denial or review for cause may result in:

• my not being considered for appointment to a position in the Government of Canada
• the termination of my employment
• the termination of my contract
• other measures in accordance with relevant legislation, policies or arrangements

I understand that, in all cases, I must be officially granted the required type and level of security screening before I can be:

• assigned to a position
• assigned duties
• granted access to sensitive information, assets or facilities

I understand that:

• my security screening file will be retained for at least 2 years after my departure from the federal public service
• if my security screening is denied or revoked, my security screening file will be retained for at least 10 years after my departure from the federal public service

Applicant’s declaration of consent

I affirm that:

• I have fully disclosed the information and documentation requested in this security screening application and consent form
• this form is complete, truthful and accurate to the best of my knowledge and belief

I consent to the use and disclosure of the personal information that has been collected in this form, and any additional information that may be collected during the security screening process, for the purposes of obtaining, revoking, updating, upgrading or reviewing for cause a reliability status and/or security clearance pursuant to the Policy on Government Security and the Standard on Security Screening.

In order to enable an assessment of my trustworthiness, my reliability, my loyalty to Canada and my reliability as it relates to my loyalty, with regard to any information and documentation provided by me in support of this security screening application, I consent to the use of this personal information by and its disclosure to:

• any authorized Government of Canada security screening official
• the RCMP, law enforcement agencies and police forces
• CSIS
• other entities, such as credit bureaus, that are internal or external to the Government of Canada

Without limiting the generality of the foregoing, my consent includes such personal information as my:

• name
• date of birth
• immigration and citizenship status in Canada
• residential history
• employment history
• educational credentials or professional designations
• fingerprints and facial image for identification purposes (as applicable)

Information about my spouse and any former spouses, relatives, roommates and cohabitants may also be shared with the RCMP, CSIS, or other law enforcement agencies and police forces when necessary to assess my reliability, my loyalty to Canada and my reliability as it relates to my loyalty.

For the purpose of the security screening process, including any update, upgrade or investigation related to my security screening, I authorize any and all persons or organizations, including public, non-public, para-public, private or governmental institutions that have information about me, to release such information to the Government of Canada upon request. Information may be collected from sources such as:

• a previous employer or identified referee
• educational institution(s) that I have attended
• professional organizations that I belong to
• credit reporting agencies

I further authorize law enforcement agencies or police forces to check and release to the Government of Canada or the RCMP any other information about me contained in any accessible records and databases under their control as described in the Standard on Security Screening. This information may include my:

• criminal history
• charges
• court orders

I understand that this consent also authorizes law enforcement agencies and/or police forces to release to the Government of Canada or the RCMP any information about me or my associations to enable an assessment of my trustworthiness and reliability. I therefore give the RCMP permission to release to the Government of Canada, in whole or in part, the information it has collected about me in relation to the security screening level that this position requires.

This consent also applies if I permanently separate as an employee of the Government of Canada and subsequently register as a supplier or private sector contractor with PSPC within the retention period identified in PIB PSU 917 (Personnel Security Screening).

This consent will remain valid for conducting verifications, inquiries, assessments and investigations, including any subsequent verifications that are required as part of an update, upgrade or review for cause, until one of the following applies:

• I no longer require reliability status, security clearance, site access status or site access clearance
• I am no longer an employee of the Government of Canada
• the arrangement that requires me to have access to sensitive information is no longer in effect
• I revoke my consent to an authorized institutional security screening official using the appropriate electronic or written means

CBSA Consent Statement

For security screening and aftercare purposes 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 protected by provisions of the Privacy Act in institutions that are covered by the Privacy Act, I consent to the disclosure by the Canada Border Services Agency (CBSA) to the Royal Canadian Mounted Police (RCMP), the Canadian Security Intelligence Service (CSIS), Immigration, Refugees and Citizenship Canada (IRCC) and law enforcement agencies, of any and all information provided by me in support of this application.

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 and third party contacts, 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 and bank account numbers provided for pay and administartion.

I, the undersigned, do consent to the disclosure of the preceding information including my fingerprints and my photograph for its subsequent verification and/or use in an investigation for the purpose of providing a security screening assessment and ongoing monitoring for aftercare as per the Standard on Security Screening, including data analytics, to confirm my suitability to hold a security status or clearance.

I hereby authorize the 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 and aftercare.

I further authorize any and all Canadian or foreign law enforcement agency - such as any Canadian or foreign police force, - or any person or organization, whether public, para public private or governmental to check, and release to the CBSA or the RCMP, all of my criminal history, charges, court orders and any other information concerning me contained in any accessible records and databases under their control. I understand that this consent also authorizes any Canadian or foreign law enforcement agency - such as any Canadian or foreign police force, - or any person or organization, whether public, para public private or governmental to release to the CBSA or the RCMP any information enabling investigation of my associates and thus enabling determination of whether I am of good character. For this same purpose, I give the RCMP permission to release to the CBSA, in whole or in part, the information it has collected during my security assessment and aftercare.

This consent is given solely for security screening and aftercare purposes. Unless withdrawn by me with notification in writing to the CBSA, this consent shall remain valid for conducting all the necessary verifications, assessments or investigations specified above, and any subsequent verification or update.

Withholding consent could result in my disqualification from the recruitment or renewal cycle process.

I certify that all the information set out by me in this application for a security clearance and aftercare, including any supporting documentation, is true and correct to the best of my knowledge and belief.

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.