Security assessment application—temporary worker/international student

Bilingual PDF (198KKB) (Alternative formats and plug-ins)

Protected "B" when completed

A. Registered person information

(This section to be completed by the designated official)

1. Type of application
2. Preferred language of correspondence

Business information

10. Description of the controlled goods the applicant will be required to examine, possess or transfer (refer to the Controlled Goods List contained in the Schedule to the Defence Production Act (hereafter referred to as the CGL) in conjunction with the Guide to the New Schedule to the Defence Production ActFootnote 1 and provide the CGL entry and applicable sub-entries).
10 a.
10 b.
10 c.

B. Privacy Act statement

The personal information collected on this form is required to perform a security assessment in order to determine the risk posed by individuals for the unauthorized transfer of controlled goods. A refusal to provide information will result in the applicant being prohibited access to controlled goods. The personal information on this form is collected and used under the authority of section 38 and section 39.1 of the Defence Production Act and in accordance with the Privacy Act.

The information collected on this form may be disclosed to law enforcement and other government departments and agencies, including foreign governments, which conduct checks and/or investigations in accordance with memoranda of understanding (MOUs) established with Public Works and Government Services Canada (PWGSC)). These checks assist in conducting security assessments on individuals and support decisions which may lead to the applicant being limited or prohibited from examining, possessing or transferring controlled goods. The personal information collected is described in PIB PWGSC PPU 045 (controlled goods registry information).

Individuals have a right of access to, correction of and protection of personal information collected on this form in accordance with the Privacy Act.

Sign and date

C. Consent to a security assessment

(To be signed by the applicant)

I, the undersigned, consent to a security assessment to determine the risk posed for the unauthorized transfer of controlled goods. I understand that my personal information may be disclosed to law enforcement, and other government departments and agencies, including foreign governments, which conduct checks and/or investigations in accordance with MOUs established with Public Works and Government Services Canada (PWGSC). By consenting to a security assessment, I am also consenting to the collection of a credit report and for the purposes of conducting a criminal history check, fingerprinting, if required.

My consent will remain valid until I no longer require access to controlled goods or when my term of employment or contract with the business listed in section A of this application is terminated.

I understand that if I refuse to provide consent I will be prohibited from accessing controlled goods.

Consent

Warning:

Any false or misleading statement on this form or relating to any document in support of this application, including concealment of any material fact, may lead to the denial, suspension or revocation of exemption from registration with the Controlled Goods Program and be grounds for criminal prosecution under section 44 of the Defence Production Act.

Failure to complete all required sections of this form will result in delays and your application may be returned.

This section is to be completed by the applicant

In any instance where this form does not allow sufficient space for a complete answer, please attach a separate page as required. Please ensure to number, sign and date each separate page.

The information requested is in respect of the five (5) year period immediately preceding the date of this security assessment application.

D. Biographical information

(Attach evidence to validate your identity (copy of government issued identification))

14. Gender
16. Other names used (include former names, nicknames, aliases, maiden name, etc.)
17. Indicate any change of name
17 a. Other names used
17 b. Other names used
18. Address (in Canada)
19. Telephone number

E. Country of origin

21. List all citizenships (country)

F. Residential history

27. List all places of residence and include duration of stay, beginning with your current address. (leave no gaps).
  • 27 a. Places of residence
  • 27 b. Places of residence
  • 27 c. Places of residence
  • 27 d. Places of residence
  • 27 e. Places of residence

G. Educational history

28. List all current and past domestic and foreign educational institutions attended and all fields of study, beginning with the most recent and include the duration of study.
  • 28. a. Educational history
  • 28. b. Educational history
  • 28. c. Educational history
  • 28. d. Educational history
  • 28. e. Educational history

H. Employment history

29. List all domestic and foreign employment activities (including full-time, part-time, temporary and self-employment) along with periods of unemployment beginning with the most recent (leave no gaps)
  • 29. a. Employment or unemployment
  • 29. b. Employment or unemployment
  • 29. c. Employment or unemployment
  • 29. d. Employment or unemployment

I. Criminal history

30. Do you have a criminal record?
31. If you have been convicted of a criminal offence in any country including Canada for which you have not been granted a pardon, provide a description of the charges, name of the police agency, city, province/state and country, date of conviction, full name at the time of the conviction.
31 a. Conviction
31 b. Conviction
31 c. Conviction
32. If you have been detained, arrested in the past or the subject of a criminal action in any country including Canada, specify the occurrence, provide details of the detention or arrest and reason for criminal action, city, province or state and country, date and occurrence status.
32 a. Details
32 b. Details
32 c. Details

J. Travel history

33. List all valid passport(s) currently in your possession or those held in the past and provide name of the country of issuance, passport number, date of issuance, name on passport, and expiry date.
33 a. Passport
33 b. Passport
33 c. Passport
34. Provide a list of all the countries you have visited, the number of visits, the purpose and the dates of travel (if you travel frequently you may group the travel per country per time frame).
34 Ex. 1
34 Ex. 2
34 a. country
34 b. country
34 c. country

K. Personal references

35. Provide the following information with respect to three persons who have known you personally for at least five (5) years that can confirm the information in your application. (No family members or cohabitants).
35 a. Reference
35 b. Reference
35 c. Reference

L. Security clearance

36. If you possess a valid security clearance, indicate the level, the country of issuance, the issuing government department and the expiry date.



Consent

I, the undersigned, hereby give my consent to the Controlled Goods Program and the designated official of the above-mentioned registered business to use the security clearance that I obtained from the above-mentioned government and any information relative to such clearance.

I, the undersigned, certify that the information
Footnote 1

In the case of any discrepancy, the Controlled Goods List (CGL) to the Defence Production Act takes precedence over the Guide

Return to footnote 1 referrer