Security Clearance Fingerprint Third Party Consent to Release Personal Information - Cannabis Act

For the purpose of your security clearance application, a Canadian police force, the Royal Canadian Mounted Police (RCMP), or private fingerprinting agencies accredited by the RCMP can submit, on your behalf, your fingerprints electronically to the RCMP for the purpose of a criminal record check. The fees for taking electronic fingerprints vary and must be paid by the applicant at the time the service is performed.

• I, (Please print full Name of the person applying for a security clearance)
• Born, (Day), (Month), (Year) require criminal record verification in order to obtain
• a (Specify job title and name of applicant or licence holder under the Cannabis Act)

• I, (Please print full Name of the person applying for a security clearance)
• Born, (Day), (Month), (Year) require criminal record verification in order to obtain
• a (Specify job title and name of applicant or licence holder (corporation and individual) under the Cannabis Act)

I hereby authorize the RCMP central repository of criminal records to release my Criminal Records Fingerprint Verification results to the following party:

Health Canada
AL: 0300A
Ottawa, Ontario
K1A 0K9

• NOTE: To avoid any delays, an ink print MUST be placed in the box below in order for your prints to be processed in a timely manner. Please circle the finger used for the Biometric Consent.
  • Right Thumb
  • Left Thumb
  • Right Index
  • Left Index
  • Right Middle
  • Left Middle
  • Right Ring
  • Left Ring
  • Right Pinkie
  • Left Pinkie
• Applicant Signature
• Dated this ( ) day of ( ) , ( )

General:

1. This form is to be brought with the applicant to the local Police Station or RCMP private accredited fingerprint agency where their fingerprints will be taken.
2. This form must be completed in front of the person taking the fingerprints.
3. It is very important that a single digit ink print be placed in the box on the form and the finger used identified by circling the appropriate one next to the box. Failure to do so will result in delays.
4. This form must be signed and dated by the applicant.
5. This form must be submitted to the RCMP at the same time as fingerprints taken on Form C-216C at your local police station, RCMP or private accredited fingerprinting agency accredited by the RCMP, whether electronically or by mail (in case of roll and ink prints).

Form C-216C is the standard RCMP Form used for fingerprinting