Security Clearance Application – Consent and Certification

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Providing misleading or false information on this application may result in a refusal or cancellation of the security clearance.

For security clearance purposes, I consent to the disclosure by the Royal Canadian Mounted Police (RCMP) to other law enforcement agencies, of any and all information provided by me in support of this application. Without limiting the generality of the foregoing, this includes information relating to my date of birth, education, residential history, employment history, and immigration and citizenship status in Canada. I also consent to the disclosure and use of my fingerprints and facial images for identification purposes.

I consent to the disclosure by law enforcement agencies to Health Canada and/or the RCMP of any and all information relevant to this security clearance application, including information in my criminal record and any other information contained in law enforcement records, including information gathered for law enforcement purposes, as well as any and all information that will facilitate the conduct of a security assessment. This includes non-conviction information, charges before the courts, findings of guilt or convictions and court orders registered in my name in the National Repository of Criminal Records and local records available to police services.

For security clearance purposes, I hereby authorize Health Canada to seek, verify, assess, collect, and retain for a period of two (2) years after the expiry date of the licence holder's licence, 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, 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. This includes non-conviction information, charges before the courts, findings of guilt or convictions and court orders registered in my name in the National Repository of Criminal Records and local records available to police services.

For security clearance purposes only, I consent to the release by other Canadian institutions or agencies to Health Canada, of information relevant to this application for a security clearance to enable Health Canada to perform security screening assessments in order to determine whether a security clearance should be granted to me.

This consent is given solely for security clearance purposes. Unless cancelled in writing by me and notification is given in writing to Health Canada, this consent shall remain valid for conducting all the necessary verifications, specified checks, assessments and/or investigations, including any subsequent required verifications, if need be, as well as any requirements for updates.

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

Applicant Name Printed in Block Letters

Applicant's Signature

Date (YYYY/MM/DD)

Home telephone

Work telephone

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