Residency and Travel Outside of Canada Questionnaire

Protected A when completed

The information on this form is required for the purpose of providing a security screening assessment. It is collected under the authority of subsection 7(1) of the Financial Administration Act and the Policy on Government Security (PGS) 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. Depending on the level of security screening required, the information collected by the government institutions may be disclosed to the Royal Canadian Mounted Police (RCMP) and the Canadian Security Intelligence Service (CSIS), which conduct the requisite checks and/or investigation in accordance with the PGS 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).

• Security File Number (Office use only)
• Family Name
• Full Given Name(s) (Underline name used)
• Date of Birth (YYYY/MM/DD)

Instructions for Residency or Travel Outside of Canada Questionnaire

For Reliability Status or Site Access Status, in accordance with the Policy on Government Security (PGS) Standard on Security Screening, a verification of the last 5 years residency in Canada is required to support the personnel screening assessment. If you lived or travelled abroad for 6 consecutive months or more during the last five (5) years, complete the following form.

Please note, the Personnel Security Screening Section may request the completion of this form when an applicant has been out of the country less than 6 consecutive months.

For Secret, Top Secret Clearance or Site Access Clearance, in accordance with the Policy on Government Security (PGS) Standard on Security Screening, a verification of the last 10 years residency in Canada is required to support the personnel screening assessment. If you lived or travelled abroad for 6 consecutive months or more during the last ten (10) years, complete the following form.

Please note, the Personnel Security Screening Section may request the completion of this form when an applicant has been out of the country less than 6 consecutive months.

This questionnaire also applies to persons who were born outside of Canada holding Dual Citizenship (for example, if born abroad of Canadian parents) and who have not resided in Canada in the past 5 years (for Reliability Status) and 10 years (for Confidential, Secret or Top Secret Clearance).

If space allotted in any portion of this questionnaire is insufficient, use separate sheet(s) using same format. Indicate your name and DOB on the top of each additional sheet you utilize.

• Level of Security Screening Required (office use only)
  • Reliability Status
  • Confidential
  • Secret
  • Top Secret
• Status In Canada
  • Citizen of Canada
  • Naturalized Canadian
    • Number Certificate
    • Date of Issue (YYYY/MM/DD)
  • Landed Immigrant
    • Date of Entry into Canada (YYYY/MM/DD)
  • Multi-Citizenship - if multiple Citizenships, indicate all Citizenships
• Record of Residency or Travel Outside of Canada
  • City/Country where you resided or visited
    • Period of time abroad From (YY/MM/DD) To (YY/MM/DD)
    • Where did you live abroad? (Provide address including City, Street, Province/State and Country)
    • Purpose (Identify appropriate purpose below)
      • Representative of the Government of Canada
      • School
      • Military
      • Work
      • Pleasure
      • Other (specify)
    • How did you financially sustain yourself while abroad? (Provide details)
    • With whom did you travel/stay with while abroad? (Provide name, relationship and Citizenship)
• Have you sworn an oath of allegiance to any country other than Canada? (Yes/No) If yes, provide which country and the reasons why.
• Do you currently hold a valid passport from another country (other than Canada)? (Yes/No)
• Have you, during the past ten (10) years, had any professional or social contacts with representatives of foreign governments? If so, which government(s) and under what circumstances?
• Do you have any business, financial or personal assets outside Canada? (Yes/No) If yes, list your assets and relevant countries (exclude stocks and mutual funds purchased in Canada).
• Do you currently financially support any person or organization outside of Canada? Provide details (name, relationship, reason etc.)
• If you attended school(s) abroad, identify name(s) and address(es) of school, courses taken and length of time at these institutions. (If proof of study (e.g. diploma, letter from institution, course schedule) is available, submit copies with this questionnaire).
• If you worked abroad, identify company(ies), address(es), your title and the length of time employed. (If proof of work is available (reference/commendation letters, attestation letter from employer) submit with this questionnaire).
• Have you ever served in the Military abroad? If so, for what country, during what period(s) of time, and what was your rank? (If proof of Military service is available (e.g. discharge papers, certificates, letter from institution), submit copies with this questionnaire).
• Have you ever been convicted of a criminal offence during your stay and/or travels abroad? (Yes/No)
  • If yes (Give details of the charge(s), City, Province/State, Country and date(s) of convictions(s).
• Association with persons outside of Canada (Only include persons you continue to have regular contact with; for example - contact by phone, email, chatting, social networking, etc.)
  • Full Given Name (no initials)
    • Relationship (Family, Friend, Former Colleague, Other (specify)
    • Citizenship
    • Place of Residence (full address)
    • How many years have you known this individual?
    • Are you aware if the person(s) listed below have a Criminal Record? Type?
  • Were you affiliated to any Associations/Clubs or Groups while living abroad?
  • Do you still have contact or are you actively involved with Associations/Clubs or Groups located abroad? (If yes, provide the full name and address of the Associations/Clubs or Groups with a description of their activities)
  • Do you know if these Associations/Clubs or Groups could be considered radical or extreme? (If yes, provide the reason(s)).
  • Do you have family, friends or former colleagues which you believe could be considered radical or extreme? Provide name(s) of the individual(s) and what activities you suspect they are involved in.

I, the undersigned, do consent to the disclosure of the preceding information including my photograph for its subsequent verification and/or use in an investigation for the purpose of providing a security screening assessment. By consenting to the above, I acknowledge that the verification and/or use in an investigation of the preceding information may also occur when the reliability status, security clearance or site access are updated or otherwise reviewed for cause under the Policy on Government Security. 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 authorized security official.

• Signature
• Date (YYYY/MM/DD)

Date modified:

2017-04-26