HTML version of the Security Clearance Form

Protected (when completed)

Office Use Only

• Reference number:
• Department number:
• File number:

The Privacy Act Statement

The information on this form is required for the purpose of providing a security assessment. It is collected under the authority of subsection 7(1) of the Financial Administration Act and the Government Security Policy (GSP) 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. The information collected by the government institution may be disclosed to the Royal Canadian Mounted Policy (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).

Please typewrite or print in block letters

Note:

• Level I and II must complete sections A to J inclusive and P.
• Level III must complete all sections.

A. Administrative Information (To be completed by Department/Agency/Organization)

• New
• Update
• Upgrade
• Transfer
• Supplemental
• Re-activation

Level:

• I (CONFIDENTIAL)
• II (SECRET)
• III (TOP SECRET)
• Other:

• Department/Agency/Organization:
• Employee ID number/PRI/Rank and Service number (if applicable):
• Organization number:

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

1. Surname (Last Name):
2. Full given names (no initials) underline or circle usual name used:
3. Family name at birth:
4. All other names used (i.e. Nickname):
5. Sex:
   • Male
   • Female
6. Date of birth:
   • Year:
   • Month:
   • Day:
7. Place of birth:
   • City:
   • Province/State:
   • Country:
8. Name change (other than marriage):
   • From:
   • To:
9. Place of change (city, province or state, and country):
10. Method (authority):

C. Security Screening

1. Have you previously completed a Government of Canada security screening form?

• Yes
• No

If yes, give name of department/agency/organization, and the year and level of clearance.

• Department/agency/organization:
• Year:

D. Marital Status/Common-Law Partnership

Current status:

• Married
• Common-Law Partnership
• Separated
• Widowed
• Divorced
• Single

1. Current Spouse/Common-Law Partner: Surname, given names:
2. Maiden Name (if applicable):
3. Present citizenship of current spouse/common-law partner:
4. Date of marriage/common-law partnership:
   • Year:
   • Month:
   • Day:
5. City, province or state, and country of marriage/common-law partnership:
6. City, province or state, and country of birth:
7. Date of birth:
   • Year:
   • Month:
   • Day:
8. Present address (apartment number, street number, street name, civic number (if applicable), city, province or state and country):
9. If separated, widowed or divorced, specify date:
   • Year:
   • Month:
   • Day:
10. Name and address of employer (job title):

1. Previous Spouse/Common-Law Partner: Surname, given names (cover only the past five years):
2. Present citizenship of former spouse/common-law partner:
3. Date of marriage/common-law partnership:
   • Year:
   • Month:
   • Day:
4. City, province or state, and country of marriage/common-law partnership:
5. Date of divorce/separation/deceased:
   • Year:
   • Month:
   • Day:
6. City, province or state and country of divorce:
7. Country of Birth (if known):
8. Date of birth:
   • Year:
   • Month:
   • Day:

E. Immediate Relatives (including those living outside Canada) (see instructions)

Note: Do not use initials

1. Full name (surname and all given names, including maiden name):
2. Relationship:
3. City, province or state, and country of birth:
4. Date of birth:
   • Year:
   • Month:
   • Day:
5. Present address (apartment number, street number, street name, civic number (if applicable), city, province or state and country):
6. Date of death:
   • Year:
   • Month:
   • Day:
7. Name and address of employer:
8. Job title:

1. Full name (surname and all given names, including maiden name):
2. Relationship:
3. City, province or state, and country of birth:
4. Date of birth:
   • Year:
   • Month:
   • Day:
5. Present address (apartment number, street number, street name, civic number (if applicable), city, province or state and country):
6. Date of death:
   • Year:
   • Month:
   • Day:
7. Name and address of employer:
8. Job title:

1. Full name (surname and all given names, including maiden name):
2. Relationship:
3. City, province or state, and country of birth:
4. Date of birth:
   • Year:
   • Month:
   • Day:
5. Present address (apartment number, street number, street name, civic number (if applicable), city, province or state and country):
6. Date of death:
   • Year:
   • Month:
   • Day:
7. Name and address of employer:
8. Job title:

1. Full name (surname and all given names, including maiden name):
2. Relationship:
3. City, province or state, and country of birth:
4. Date of birth:
   • Year:
   • Month:
   • Day:
5. Present address (apartment number, street number, street name, civic number (if applicable), city, province or state and country):
6. Date of death:
   • Year:
   • Month:
   • Day:
7. Name and address of employer:
8. Job title:

1. Full name (surname and all given names, including maiden name):
2. Relationship:
3. City, province or state, and country of birth:
4. Date of birth:
   • Year:
   • Month:
   • Day:
5. Present address (apartment number, street number, street name, civic number (if applicable), city, province or state and country):
6. Date of death:
   • Year:
   • Month:
   • Day:
7. Name and address of employer:
8. Job title:

1. Full name (surname and all given names, including maiden name):
2. Relationship:
3. City, province or state, and country of birth:
4. Date of birth:
   • Year:
   • Month:
   • Day:
5. Present address (apartment number, street number, street name, civic number (if applicable), city, province or state and country):
6. Date of death:
   • Year:
   • Month:
   • Day:
7. Name and address of employer:
8. Job title:

1. Full name (surname and all given names, including maiden name):
2. Relationship:
3. City, province or state, and country of birth:
4. Date of birth:
   • Year:
   • Month:
   • Day:
5. Present address (apartment number, street number, street name, civic number (if applicable), city, province or state and country):
6. Date of death:
   • Year:
   • Month:
   • Day:
7. Name and address of employer:
8. Job title:

F. 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 and date of conviction):

• Charge(s):
• Name of policy force:
• City:
• Province/State:
• Country:
• Date of conviction:
  • Year:
  • Month:
  • Day:

G. For Completion By Persons Born Outside Canada or Born In Canada Holding Dual Citizenship (see instructions)

1. Date of entry into Canada:
   • Year:
   • Month:
   • Day:
2. Present citizenship:
3. If you are a naturalized Canadian, give the certificate number and date of issue:
   • Certificate No.:
   • Date of issue:
     • Year:
     • Month:
     • Day:
4. If you are not naturalized, have you applied for Canadian citizenship? Please provide a copy of Immigrant Visa or Record of Landing documentation:
   • Yes
   • No
   • Date of application:
     • Year:
     • Month:
     • Day:
5. Do you maintain citizenship of a country other than Canada? If yes, please provide the name of the country and explain why:
   • Yes
   • No
   • (If yes) Name of Country:
   • Explain:
6. Have you used a passport other than a Canadian one? If yes, explain why:
   • Yes
   • No
   • (If yes) Explain:

H. Residence (there should be no gaps)

List addresses where you have lived during the last 10 years, starting with the most current. (Rural address to include lot and civic number.)

• Apartment Number:
• Street Number:
• Street Name:
• Civic Number (if applicable):
• From:
  • Year:
  • Month:
• To: present
• City:
• Province or state:
• Postal code:
• Country:
• Telephone number:

• Apartment Number:
• Street Number:
• Street Name:
• Civic Number (if applicable):
• From:
  • Year:
  • Month:
• To:
  • Year:
  • Month:
• City:
• Province or state:
• Postal code:
• Country:
• Telephone number:

• Apartment Number:
• Street Number:
• Street Name:
• Civic Number (if applicable):
• From:
  • Year:
  • Month:
• To:
  • Year:
  • Month:
• City:
• Province or state:
• Postal code:
• Country:
• Telephone number:

• Apartment Number:
• Street Number:
• Street Name:
• Civic Number (if applicable):
• From:
  • Year:
  • Month:
• To:
  • Year:
  • Month:
• City:
• Province or state:
• Postal code:
• Country:
• Telephone number:

• Apartment Number:
• Street Number:
• Street Name:
• Civic Number (if applicable):
• From:
  • Year:
  • Month:
• To:
  • Year:
  • Month:
• City:
• Province or state:
• Postal code:
• Country:
• Telephone number:

I. Employment (last 10 years) (see instructions for self-employed and consultants) (there should be no gaps)

Would your employment be jeopardized if your current supervisor, below, is contacted?

• Yes
• No

If yes, provide the name of an alternate employment contact and telephone number:

Were you dismissed or asked to resign from any position(s) listed below?

• Yes
• No

If yes, give name of employer, supervisor, and date.

• Name of employer:
• Supervisor:
• Position title:
• Date:
  • Year:
  • Month:

1. Name of employer - do not use initials (department/organization/agency, if applicable)
2. From:
   • Year:
   • Month:
   To: present
3. Job-site address (street number, street name, city, province or state and country):
4. Job title/Description:
5. Rank and service number (if applicable):
6. Supervisor’s name in full:
7. Supervisor’s telephone number:

1. Name of employer - do not use initials (department/organization/agency, if applicable)
2. From:
   • Year:
   • Month:
   To:
   • Year:
   • Month:
3. Job-site address (street number, street name, city, province or state and country):
4. Job title/Description:
5. Rank and service number (if applicable):
6. Supervisor’s name in full:
7. Supervisor’s telephone number:

1. Name of employer - do not use initials (department/organization/agency, if applicable)
2. From:
   • Year:
   • Month:
   To:
   • Year:
   • Month:
3. Job-site address (street number, street name, city, province or state and country):
4. Job title/Description:
5. Rank and service number (if applicable):
6. Supervisor’s name in full:
7. Supervisor’s telephone number:

1. Name of employer - do not use initials (department/organization/agency, if applicable)
2. From:
   • Year:
   • Month:
   To:
   • Year:
   • Month:
3. Job-site address (street number, street name, city, province or state and country):
4. Job title/Description:
5. Rank and service number (if applicable):
6. Supervisor’s name in full:
7. Supervisor’s telephone number:

J. Foreign Employment

Are you now or have you ever been employed by or acted as a consultant for a foreign government, firm or agency?

• Yes
• No

If yes, give details (country, organization, nature of work and dates) Include military (cadets), law enforcement and security intelligence employment:

Sections "K" to "O" must also be completed for level III only

K. Travel

List countries visited within the last five years for personal travel and/or non-Government business, other than Canada, the USA and Mexico.

• Country:
• Purpose:
• From:
  • Year:
  • Month:
• To:
  • Year:
  • Month:

• Country:
• Purpose:
• From:
  • Year:
  • Month:
• To:
  • Year:
  • Month:

• Country:
• Purpose:
• From:
  • Year:
  • Month:
• To:
  • Year:
  • Month:

• Country:
• Purpose:
• From:
  • Year:
  • Month:
• To:
  • Year:
  • Month:

• Country:
• Purpose:
• From:
  • Year:
  • Month:
• To:
  • Year:
  • Month:

L. Foreign Assets

Do you have any business, financial or personal assets outside Canada?

• Yes
• No

If yes, list the relevant countries (exclude stocks and mutual funds purchased in Canada):

M. Character References in Canada (see instructions)

List three character references (non-family members) and one neighbourhood reference

• Name in full (no initials):
• Relationship:
• Period known:
• Complete home address:
• Telephone Number:
• Complete title and business address:
• Business Telephone number:

• Name in full (no initials):
• Relationship:
• Period known:
• Complete home address:
• Telephone Number:
• Complete title and business address:
• Business Telephone number:

• Name in full (no initials):
• Relationship:
• Period known:
• Complete home address:
• Telephone Number:
• Complete title and business address:
• Business Telephone number:

Neighbourhood reference (see instructions)

• Name in full (no initials):
• Telephone Number:
• Complete home address:
• Business Telephone number:

N. Education

1. Name of the last school or university you attended full time:
2. Student ID number (if known):
3. Location of institution
4. Period of attendance:
   • From:
     • Year:
     • Month:
   • To:
     • Year:
     • Month:
5. Field of study (Diploma or degree obtained):

O. Military Service

Military service in the Canadian Armed Forces: Regular, Reserves and Sea, Army and Air Cadets (from the period since your 16th birthday).

1. Name and last location:
2. Rank and Service no.:
3. Period of service:
   • From:
     • Year:
     • Month:
   • To:
     • Year:
     • Month:

P. Certification

I hereby certify that the information set out by me in this document is true and correct to the best of my knowledge and belief.

1. Signature:
2. Date:
   • Year:
   • Month:
   • Day:
3. Telephone (Home):
4. Telephone (Business):

All information supplied is subject to verification by investigation

Instructions for completion of security clearance form TBS/SCT 330-60E (Rev. 2006-02)

General

• Once completed this form shall be safeguarded and handled at the level of PROTECTED A.
• If clarification of information is required, a Canadian Government Official may contact the applicant to obtain additional information in order to complete the security screening investigation and an interview of the applicant may be requested.
• This form is to be completed using an automated system or if not available using a typewriter or printing in block letter format in black ink.
• Please read and follow these instructions carefully.
• The original signed copy must be submitted.
• It is important that a copy of the completed questionnaire be retained by the applicant for future reference.
• Incomplete or illegible forms will not be considered.
• All names are to be in full (no initials) (Maternal and Paternal or other names used).
• Addresses are to include, where applicable civic or township name and the lot and concession numbers.
• If information is not known or is unavailable please indicate this on the form and on a separate sheet of paper explain the cause of circumstance.
• All dates are to be entered in order of Year, Month and Day as applicable.
• If space allotted in any portion is insufficient please use separate sheet using same format.

Detailed Instructions:

Section A

• To be completed by the department, agency or organization.
• "Other" This should be used to identify if the security screening is for Site Access, NATO, SIGINT etc.

Section B (Remainder of the form is to be completed by the applicant)

• Complete as requested.

Section C

• Complete as requested.

Section D

"Common-law partner" - in relation to an applicant, means a person who is cohabiting with the individual in a conjugal relationship, having so cohabited for a period of at least one year. This includes persons of the same sex.

• 1. includes current spouse and common-law partner as applicable.
• If any person is deceased, date of death and last address while living are to be shown.
• 2. includes previous spouse and common-law partner as applicable during the last five years.
• If a person is deceased, date of death is to be shown in 2e.
• All other questions to be answered as set forth.

Section E

• Questions 1 to 8 - experience has shown that incomplete answers to these questions are the most common cause of delay. Please follow the instructions carefully.
• For all security clearance requests all Immediate Relative(s) information must be provided.
• Immediate family includes the following:
  • All children 18 years and over that you or your spouse or common-law partner have a parental relationship.
  • Your father, mother, brothers, sisters. Include "half" or "step" relatives in this category.
  • Your current spouse’s or common-law partner’s father and mother. Include "half" or "step" relatives in this category

If any person is deceased, date of death and last address while living are to be shown.

Section F

• 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.

Section G

• If a naturalized Canadian, it is important to show the certificate number, date of issue. Attach a photocopy of the certificate.
• If born abroad of Canadian parents, please provide a copy of your Certificate of Registration of Birth Abroad.
• If not a Canadian Citizen indicate if application has been made for Citizenship. In this case, passport or identity card number and particulars should be recorded in a box "6". Please provide copy of Immigrant Visa or Record of Landing documentation.
• Question 5 and 6 - Attach a separate sheet of paper if more space is required. Each sheet must be signed.

Section H

• As set forth, ensuring current address is recorded first.
• The Postal code is mandatory for the current address, and if known, for previous addresses.
• For rural area, include civic number or lot, concession and township number.

Section I

• Record your present employment first.
• Please note that it may be necessary to contact your present employer.
• Time at school and periods of unemployment are also to be shown; (as well as, secondments, educational leave, and courses of over six months’ duration; include supervisor or colleague’s name).
• Job-site address is the address where your work is performed and may be different from your employer’s address.

Note: If you are self-employed or a consultant, or have been self-employed or a consultant, provide the following:

• Name of employer - give your business name; if not applicable, give your name;
• No change;
• Job-site address - give your permanent business address; if not applicable, give your residence address;
• No change;
• No change;
• Supervisor’s name - give a name of a person who can verify your employment;
• No change.

Section J

• Is related to determining past employment of security concern. A security official may ask for further details.

Section K

• Travel record is for less than six months, if more than this period it is to be recorded as residence in part "H".
• One day visits to countries, such as cruise stopover, do not have to be recorded.
• A security official may ask for details of travel.
• An employee or contractor on Canadian Government business is not required to record details of travel in this section.

Section L

• A security official may ask for details in terms of the types of assets and estimated value.

Section M

• Character references must be colleagues, peers, and friends who have known you well for over three years and should be able to cover your non-work environment and activities.
• Character references are not to include relatives and must be residing in Canada.
• Faster processing is facilitated if references listed are in your geographic area.
• Neighbourhood reference is an individual who has known you for over six months preferably at your current address. If not, the individual has been a neighbour during the past five years.

Section N

• Complete as requested.

Section O

• Question to be answered if not covered is employment section. List last or current unit and dates of total service in the Canadian Armed Forces.
• If more space is required use a separate sheet of paper. Each sheet must be signed.

Section P

• Complete as requested.

Supplemental Information Requirements

Persons who have previously completed a Security Clearance and subsequently marry, remarry or commence a common-law partnership are required to submit an original Security Clearance Form with the following parts completed:

For all Security Clearances

• Part A - As set forth in each question
• Part B - As set forth in each question
• Part C - As set forth in each question
• Part D - As set forth in each question
• Part E - Provide details on parents of new spouse/common-law partner and any children (over the age of 18 years) of the new spouse/common-law partner
• Part P - To be signed by person submitting the form

Note: In addition to the above, in those cases where an individual marries or commences a common-law partnership with a Non-Canadian National or Landed Immigrant who has not yet arrived in Canada, the following information is required:

• Part A-D - As set forth in each question
• Part E - Parents of new spouse/common-law partner, brothers, sisters (include "half" and "step" relatives) and any children (over the age of 18 years) of the new spouse/common-law partner
• Part H - For new spouse/common-law partnership
• Part I - For new spouse/common-law partnership
• Part P - To be signed by person submitting the form

Cyclical Update Requirements

• Level I+II (10 year update). Complete all portions of the form as per instructions above.
• Level III (5 year update cycle)

With the exceptions of Parts H and I, where the information required is that which covers the period of time since the last submission of a questionnaire, all other parts of the questionnaire must be completed in full.

TBS/SCT 330-60E (Rev. 2006/02)