Consent to release of reliability screening and/or security clearance information

Protected (when completed)

This form must be used to authorize the Contract Security Program (CSP) to disclose an individual’s reliability screening and/or security clearance level(s) to authorized security officials of organizations registered in the program. The program will only disclose information used to validate whether or not an individual is eligible, from a security perspective, to perform work on federal government contracts that contain security requirements.

This form must be completed when an individual wants to provide consent to an organization registered in the Contract Security Program other than the organization through which the individual had originally submitted a Personnel Screening Consent and Authorization Form.

Without this prior written consent, the program would not be able to provide an individual's reliability screening or security clearance level information to organizations, other than the organization through which the individual had originally submitted a Personnel Screening Consent and Authorization Form.

If an individual chooses not to provide consent as provided in this form, the Government of Canada takes no responsibility for any negative impact this inability to disclose a person's reliability screening or security clearance level information could have on the person's employment or prospective employment in relation to a Government of Canada contract or request for proposal (RFP).

Instructions

To provide consent, choose either option 1 or option 2. Do not choose both. Details of each option are provided on the consent form, which state:

Within option 2 there are two further choices, (a) and (b). You must select either sub-option (a) or sub-option (b). Sub-option (a) allows you to consent to the disclosure of your reliability screening and/or security clearance information to a specific organization, but does not limit the disclosure to a specific contract or RFP. Sub-option (b) allows you to consent to the disclosure of your reliability screening and/or security clearance information to a specific organization and in relation to a specific Government of Canada contract or RFP.

Also within option 2, the program will revoke all consent forms previously received unless you indicate otherwise by selecting the box to reflect that you do not want this to occur.

The company security officer (CSO) or alternate company security officer (ACSO) must also sign this form attesting that they have provided the individual with the instructions and explained the options available under the consent form.

Submitting the consent form

Submission of this form can be performed using any of the following methods:

Email:
consentementPSI-ISPconsent@tpsgc-pwgsc.gc.ca
Fax:
613‑960‑1883
Mail:
Contract Security Program
Public Services and Procurement Canada
Consent Form Division
2745 Iris Street
c/o PSPC Central Mail Room
Portage III, 0B3
11 Laurier St
Gatineau QC  K1A 0S5

Privacy Act statement

The information collected on this form will be used to provide a record of an individual's consent to disclose reliability screening and/or security clearance level information to authorized security officials of organizations registered in the Contract Security Program. The information provided is collected under the authority of the Policy on Government Security of the Government of Canada. The personal information collected will be stored in personal information bank PSPC PPU 015. It is protected from disclosure to unauthorized persons/agencies pursuant to the provisions of the Privacy Act. Under this act, you have the right to request access to your personal information, held by a federal government institution, and to request corrections should you believe the information contains errors or omissions. The information will be retained by the department for two years following the last administrative use and then destroyed.

Consent

If you desire to consent to the release of your reliability screening and/or security clearance information to any organization registered in the Contract Security Program, complete this form and select option 1. If you desire to limit the disclosure of your reliability screening and/or security clearance information to a specific organization only, select option 2, sub-option (a) or to a specific organization only and a specific contract or request for proposal (RFP), select option 2, sub-option (b).

hereby consent to the disclosure by Public Services and Procurement Canada of information relating to my reliability screening and/or security clearance level (including name, personal identification number, level and status of security screening/clearance, initiation, completion, granting and renewal dates) subject to the following terms:

Select either Option 1 or Option 2 (required)
Revocation of all consent forms that I have previously submitted and disclosure, upon a request by any authorized security official of any organization registered in the Contract Security Program, to the requesting security official for the purpose only of verifying whether I have the necessary reliability screening and/or security clearance level required by a contract or RFP in order that I can provide services to the Government of Canada pursuant to the said contract or RFP.
Revocation, unless indicated below, of all consent forms that I have previously submitted and disclosure, upon a request by an authorized security official of

provided such organization is registered in the Contract Security Program, to the requesting security official for the purpose only:

Select either (a) or (b) (required)
verifying whether I have the necessary reliability screening and/or security clearance level required by a contract or RFP in order that I can provide services to the Government of Canada pursuant to the said contract or RFP.
of verifying whether I have the necessary reliability screening and/or security clearance level required in order to provide

to the Government of Canada pursuant to either

or

as the case may be.

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 Contract Security Program.

Company security officer declaration

I, the undersigned, as a CSO/ACSO of,

have presented, discussed, and explained the instructions and consent options available to the individual.

To be completed by the program

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