Personnel Screening, Consent and Authorization Form

Protected (when completed)

Important Notes:

The Personnel Screening, Consent and Authorization Form will permit you to print the information that you have entered but will not permit you to save the form.
Prior to entering any data, please ensure that you have all of the required information on hand. For completion instructions refer to the instructions section.

Administrative Information

Administrative Instructions

The information required in this section has been sent to you by your hiring official. If you did not receive all the required information, please contact your hiring official.

Department

Hiring Official Name

Hiring Official E-mail address

Type of request

Requested level of reliability/security

Have you lived or travelled abroad for 6 consecutive months or more during the last five (5) years?

Residency and Travel Outside of Canada Instructions

If applicable, select “Yes” for the following questions: “Have you lived or travelled abroad for 6 consecutive months or more during the last five (5) years?” (Note that for Reliability Status requests it will indicate 5 years and for Secret/Top Secret requests it will indicate 10 years).

If “Yes” is selected, additional information on your time spent outside of Canada will be requested in the following sections (see referenced sections further in the instructions for additional information):

Biographical Information - Residence: a message will ask if the entry is part of the time you spent outside of Canada. You may add all applicable addresses at this stage by selecting “Yes” and entering all applicable data. To add addresses in Canada, select “No”.
Citizenship information: enter all information if applicable to you.
Employment information: enter all information if you worked while you were outside of Canada.
Travel information: indicate all as applicable.
Residency and Travel Outside of Canada Information: enter all fields as applicable. Provide as much information as possible.

Biographical Information

Biographical Instructions

Enter in all of the required fields. It is essential that you enter all the names/aliases that you use in order to ensure an accurate security assessment can be provided.

Surname (Last name)

First name

Middle names

Family name at birth

Usual name

Nickname

Other Names Used

Surname

First name

Date of birth (YYYY-MM-DD)

Gender

Personal telephone number

Primary personal e-mail address

Additional personal e-mail address

Work email

Country of birth

Province or state

Place of birth (city)

Date of entry into Canada if born outside Canada (YYYY-MM-DD)

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

Residence Instructions

Ensure that you enter all residences that you have lived at within the last five years (Reliability Status) or 10 years (Secret or Top Secret), even if the dates overlap. However, there can be no gaps in time between residences.

Current Residence

Apartment number

Street number

Street name

Civic number (if applicable)

City

Country

Province or state

Postal code

Telephone number

From (YYYY-MM)

To (YYYY-MM)

Criminal Convictions In and Outside of Canada Instructions

List only criminal convictions for which a pardon has not been granted. Applicant must include convictions outside of Canada. Offences under the National Defence Act are to be included as well as convictions by courts-martial are to be recorded.

Have you ever been convicted of a criminal offence for which you have not been granted a pardon?

If yes, give details. (charge(s), name of police force, city, province/state, country and date of conviction)

Conviction Details

Name of police force

Country

Province or state

City

Date of conviction (YYYY-MM-DD)

Charge(s)

Marital Status/Common-Law Partnership Information

Marital Status/Common-Law Partnership Instructions

“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.

Include previous spouse and common-law partner as applicable during the last five years.

Marital status

Surname

Given name

Maiden name (if applicable)

Middle names

Citizenship

Relationship

Gender

Same address as the applicant

Apartment number

Street number

Street name

Civic number (if applicable)

City

Country

Province or state

Postal code

Date of birth (YYYY-MM-DD)

City of birth

Country of birth

Province or state of birth

Date of marriage/common-law partnership (YYYY-MM-DD)

City of marriage/common-law partnership

Country of marriage/common-law parthership

Province or state of marriage/common-law parthership

If separated, widowed or divorced. Specify date (YYYY-MM-DD)

Is the current spouse/common-law partner employed?

Name and Address of Employer

Employer name

Job title

Apartment number

Street number

Street name

Civic number (if applicable)

City

Country

Province or state

Postal code

Previous Spouse/Common-Law Partner

Surname

Given name

Middle names

Apartment number

Street number

Street name

Civic number (if applicable)

City

Country

Province or state

Postal code

Date of birth (YYYY-MM-DD)

Gender

Country of birth

Citizenship

Date of marriage/common-law partnership (YYYY-MM-DD)

City of marriage/common-law partnership

Country of marriage/common-law partnership

Province or state of marriage/common-law partnership

Date of divorce/separation/deceased (YYYY-MM-DD)

City of divorce/separation/deceased

Country of divorce/separation/deceased

Province or State of divorce/separation/deceased

Immediate Relatives Information

Immediate Relatives Instructions

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 and sisters. Include “half” or “step” relatives as well.
Your current spouse’s or common-law partner’s father and mother. Include “half” or “step” relatives as well.

If any relative mentioned above is deceased, the date of death and the last address while living is to be provided.

How many parents do you have?

Immediate Relative - Parent

Surname

Given name

Middle names

Maiden name (if applicable)

Relationship

Is this an estranged relative?

Date of birth (YYYY-MM-DD)

City of birth

Country of birth

Province or state of birth

Date of death (YYYY-MM-DD)(if applicable)

Apartment number

Street number

Street name

Civic number (if applicable)

City

Country

Province or state

Postal code

Is the immediate relative employed?

Name and Address of Employer

Employer name

Job title

Apartment number

Street number

Street name

Civic number (if applicable)

City

Country

Province or state

Postal code

How many parents-in-law do you have?

How many children do you have?

How many siblings do you have?

Citizenship Information

Citizenship Instructions

If you are a naturalized Canadian, it is important to show the certificate number and date of issue. A photocopy of the certificate may be requested at a later date.

If you are born abroad of Canadian parents, a copy of you Certificate of Registration of Birth Abroad may be requested at a later date.

If you are not a Canadian Citizen, indicate if an application has been made for Citizenship. In this case, passport or identity card number and particulars should be provided on the form. A copy of your Immigrant Visa or Record of Landing documentation may be requested at a later date.

Present citizenship

Status in canada

If you are not naturalized, have you applied for Canadian citizenship?

Do you maintain citizenship of a country other than Canada?

If yes, please provide the name of the country and explain why.

Name of other country

All other citizenships

Other citizenship explanation

Have you used a passport other than a Canadian one?

Employment Information

Employment Instructions

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). Indicate “unemployed” or “student” in the job title field in these cases.

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

Employer

Name of employer

From (YYYY-MM)

To (YYYY-MM)

Apartment number

Street number

Street name

Civic number (if applicable)

City

Country

Province or state

Postal code

Job title/description

Rank

Service number

Supervisor's surname

Supervisor's given name

Supervisor's telephone number

Supervisor's Email

Is this your current employer?

Is this a foreign employer?

Were you dismissed or asked to resign from this position?

Travel Information

Travel Instructions

This section is to record travel under 6 months. If you have traveled for over 6 months, you need to include the travel in your residency.

One day visits to countries, such as cruise stopover, do not have to be recorded. An employee or contractor on Canadian Government business is not required to record details of travel in this section. A security official may ask for details in regards to your travels.

Travel

Country

Purpose (identify appropriate purpose below)

From (YYYY-MM)

To (YYYY-MM)

Character References in Canada

Character References in Canada Instructions

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.

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.

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

Surname

Given name

Telephone number

Apartment number

Street number

Street name

Civic number (if applicable)

City

Country

Province or state

Postal code

Business telephone number

Surname

Given name

Relationship

Telephone number

Period known (years)

Apartment number

Street number

Street name

Civic number (if applicable)

City

Country

Province or state

Postal code

Business title

Business apartment number

Business street number

Business street name

Business civic number

Business city

Business country

Business province or state

Business postal code

Business telephone number

Surname

Given name

Relationship

Telephone number

Period known (years)

Apartment number

Street number

Street name

Civic number (if applicable)

City

Country

Province or state

Postal code

Business title

Business apartment number

Business street number

Business street name

Business civic number

Business city

Business country

Business province or state

Business postal code

Business telephone number

Surname

Given name

Relationship

Telephone number

Period known (years)

Apartment number

Street number

Street name

Civic number (if applicable)

City

Country

Province or state

Postal code

Business title

Business apartment number

Business street number

Business street name

Business civic number

Business city

Business country

Business province or state

Business postal code

Business telephone number

Education Information

Education Instructions

To be completed as requested.

Name of the last school or university you attended full time

Field of study (diploma or degree obtained)

Period of Attendance

From (YYYY-MM)

To (YYYY-MM)

Student ID number (if known)

Apartment number

Street number

Street name

Civic number (if applicable)

City

Country

Province or state

Postal code

Military Information

Military Instructions

List last or current unit and dates of total service in the Canadian Armed Forces.

Name

Rank

Service number

Period of Service

From (YYYY-MM-DD)

To (YYYY-MM-DD)

City

Country

Province or state

Residency and Travel Outside of Canada Information

Residency and Travel Outside of Canada Instructions

If applicable, indicate any and all business, financial and/or personal assets outside of Canada. Indicate all applicable details. A security officer may contact you for further information.

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

Have you sworn an oath or allegiance to any country other than Canada?

Have you, during the past ten (10) years, had any professional or social contacts with representatives of foreign governments?

Do you currently financially support any person or organization outside of Canada?

Have you attended school(s) abroad?

Have you ever served in the military abroad?

Do you have family, friends or former colleagues which you believe could be considered radical or extreme?

(Only include persons you continue to have regular contact with; for example - contact by phone, email, chatting, social networking, etc.)

Foreign Association

Full given name (no initials)

Citizenship

Relationship

Specify other

How many years have you known this individual?

Are you aware if the person listed has a criminal record?

Apartment number

Street number

Street name

Civic number (if applicable)

City

Country

Province or state

Association/Club or Group

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 putting complete below details by name and address 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).)

Note: Please direct any necessary attachments by email to the general enquiries line: Personnel.ScreeningEnquiries-CBSA@cbsa-asfc.gc.ca. Please ensure to follow naming convention: Last Name, First Name – Date of Birth in the emails subject line to properly identify the information.

Consent and Verification

Consent and Verification Instructions

Consent may be given only by an applicant who has reached the age of majority; otherwise, the signature of guardian is mandatory.

The age of majority is:

19 years in NFLD., N.S., N.B., B.C., Yukon, Northwest Territories and Nunavut;
18 years in P.E.I., Que., Ont., Man., Sask., and Alta.

The applicant is to check and initial each box.

CBSA applicant:

Reliability Screening (for all types of screening identified within the Administrative Section): complete boxes 1 and 2 and 3 and 5.
Security Clearance (for all types of screening identified within the Administrative Section): complete boxes 1 to 5.

IAAC applicant:

Reliability Screening (for all types of screening identified within the Administrative Section): complete boxes 1 and 2 and 3 if applicable.
Security Clearance (for all types of screening identified within the Administrative Section): complete boxes 1 to 4 and 5 where applicable.
Other: box 5 is used only where prior Treasury Board of Canada Secretariat approval has been obtained

Checks Required

Date of birth, address, education, professional qualifications, employment history, personal character references

Applicant's initials

Criminal record check

Applicant's initials

Credit check (financial assessment, including credit records check)

Applicant's initials

Loyalty (security assessment only)

Applicant's initials

Other (specify, see instructions)

Applicant's initials

Read the CBSA Consent Statement

CBSA Consent Statement

For security screening purposes 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 protected by provisions of the Privacy Act in institutions that are covered by the Privacy Act, I consent to the disclosure by the Canada Border Services Agency (CBSA) to the Royal Canadian Mounted Police (RCMP), the Canadian Security Intelligence Service (CSIS), Immigration, Refugees and Citizenship Canada (IRCC) and law enforcement agencies, of any and all information provided by me in support of this application.

This personal information will include any and all information I have provided throughout the application and security screening process including but not limited to: given name(s) and any other names used, surname(s) including family name at birth, DOB, sex, marital/common-law/partner information, information on immediate relatives, employment information (including foreign employment), education and activity information, criminal information, citizenship/Canadian status information, residency information, travel information, foreign assets, character reference information, military service information, credit information.

I, the undersigned, do consent to the disclosure of the preceding information including my fingerprints and my photograph for its subsequent verification and/or use in an investigation for the purpose of providing a security screening assessment.

I hereby authorize the CBSA to seek, verify, assess, collect and retain 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, information gathered through CBSA internal databases, 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.

I further authorize any and all Canadian or foreign law enforcement agency - such as any Canadian or foreign police force, - or any person or organization, whether public, para public private or governmental to check, and release to the CBSA or the RCMP, all of my criminal history, charges, court orders and any other information concerning me contained in any accessible records and databases under their control. I understand that this consent also authorizes any Canadian or foreign law enforcement agency - such as any Canadian or foreign police force, - or any person or organization, whether public, para public private or governmental to release to the CBSA or the RCMP any information enabling investigation of my associates and thus enabling determination of whether I am of good character. For this same purpose, I give the RCMP permission to release to the CBSA, in whole or in part, the information it has collected during my security assessment.

This consent is given solely for security screening purposes. Unless withdrawn by me with notification in writing to the CBSA, this consent shall remain valid for conducting all the necessary verifications, assessments or investigations specified above, and any subsequent verification or update.

Withholding consent could result in my disqualification from the recruitment or renewal cycle process.

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.

I have read the "CBSA Consent Statement" and agree to its terms.

Read the Privacy Act Statement

The Privacy Act Statement

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 institution 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 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).

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.

I have read the Privacy Act Statement and agree to its terms.

Note: If you would like to retain the information that you have entered on this form, please ensure that you print the form using your web browser’s “Print…” feature (from the File or Tools menu) before clicking on “Submit”. Once you click on “Submit”, you will no longer be able to access the completed form or its content.

Signature

Date signed

Personnel Screening, Consent and Authorization Form - Disclaimer

Users assume the risk associated with any transfer of information to the Canada Border Services Agency (CBSA). The CBSA has made all reasonable efforts to protect the confidentiality of the information you provide and to ensure that your electronic transactions with us are secure. However, the CBSA is not liable for any damages that may arise from interception, loss, theft or their action regarding your personal information while in transit.

The CBSA is not responsible for any losses or damages incurred by anyone because of any restriction, delay, malfunction, or unavailability of the Personnel Security Screening on-line screening application Form.

Users are solely responsible for the accuracy of the information provided to the CBSA via this service.

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Important Notes:

The Personnel Screening, Consent and Authorization Form will permit you to print the information that you have entered but will not permit you to save the form. Prior to entering any data, please ensure that you have all of the required information on hand.
The following links are provided as a reference only - do not complete or submit the following forms to Security. The links are provided for you to gather the required information before completing the below e-application (scroll down):
- If you are requesting a CBSA Reliability Status, you will be required to provide the information found on the Personnel Security Screening Form (TBS/SCT 330-23).
- If you are requesting a Security Clearance, otherwise known as a Secret or Top Secret, you will be required to provide the information found on the Personnel Security Screening Form (TBS/SCT 330-23) and the Security Clearance Form (TBS/SCT 330-60).
- If you have been out of the country for 6 consecutive months or more within the last 5 years for Reliability Status, and 10 years for Security Clearance, you will be required to provide the information found on the Residency and Travel Outside of Canada Questionnaire (BSF641)
Please do not begin entering any information on the Personnel Screening, Consent and Authorization Form until you have compiled all of the required information. If you have any questions related to these instructions, please contact your hiring official.
Only use letters and numbers in your application. Any special characters (#, $, %, (), {}, [], ‹›, *, etc) will result in your application not being processed. Consequently, the application will have to be redone by the applicant.

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Note: For Privacy Act Statement refer to the Consent and Verification section of this form and for completion instructions refer to the instructions section.

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Instructions for Personnel Screening, Consent and Authorization Form

Once completed, the information from this form shall be safeguarded and handled at the level of Protected A.

1. Administrative Information

The information required in this section has been sent to you by your hiring official. If you did not receive all the required information, please contact your hiring official.

2. Residency and Travel Outside of Canada

Biographical Information - Residence: a message will ask if the entry is part of the time you spent outside of Canada. You may add all applicable addresses at this stage by selecting “Yes” and entering all applicable data. To add addresses in Canada, select “No”.
Citizenship information: enter all information if applicable to you.
Employment information: enter all information if you worked while you were outside of Canada.
Travel information: indicate all as applicable.
Residency and Travel Outside of Canada Information: enter all fields as applicable. Provide as much information as possible.

3. Biographical Information

Enter in all of the required fields. It is essential that you enter all the names/aliases that you use in order to ensure an accurate security assessment can be provided.

Residence

Criminal Convictions In and Outside of Canada

List only criminal convictions for which a pardon has not been granted. Applicant must include convictions outside of Canada.

Offences under the National Defence Act are to be included as well as convictions by courts-martial are to be recorded.

4. Marital Status/Common-Law Partnership Information

Include previous spouse and common-law partner as applicable during the last five years.

5. Immediate Relatives Information

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 and sisters. Include “half” or “step” relatives as well.
Your current spouse’s or common-law partner’s father and mother. Include “half” or “step” relatives as well.

If any relative mentioned above is deceased, the date of death and the last address while living is to be provided.

6. Citizenship Information

If you are a naturalized Canadian, it is important to show the certificate number and date of issue. A photocopy of the certificate may be requested at a later date.

If you are born abroad of Canadian parents, a copy of you Certificate of Registration of Birth Abroad may be requested at a later date.

7. Employment Information

Record your present employment first. Please note that it may be necessary to contact your present employer.

8. Travel Information

This section is to record travel under 6 months. If you have traveled for over 6 months, you need to include the travel in your residency.

9. Character References in Canada

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.

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.

10. Education information

To be completed as requested.

11. Military Information

List last or current unit and dates of total service in the Canadian Armed Forces.

12. Residency and Travel Outside of Canada Information

If applicable, indicate any and all business, financial and/or personal assets outside of Canada. Indicate all applicable details. A security officer may contact you for further information.

13. Consent and Verification

Consent may be given only by an applicant who has reached the age of majority; otherwise, the signature of guardian is mandatory.

The age of majority is:

19 years in NFLD., N.S., N.B., B.C., Yukon, Northwest Territories and Nunavut;
18 years in P.E.I., Que., Ont., Man., Sask., and Alta.

The applicant is to check and initial each box.

CBSA applicant:

Reliability Screening (for all types of screening identified within the Administrative Section): complete boxes 1 and 2 and 3 and 5.
Security Clearance (for all types of screening identified within the Administrative Section): complete boxes 1 to 5.

IAAC applicant:

Reliability Screening (for all types of screening identified within the Administrative Section): complete boxes 1 and 2 and 3 if applicable.
Security Clearance (for all types of screening identified within the Administrative Section): complete boxes 1 to 4 and 5 where applicable.
Other: box 5 is used only where prior Treasury Board of Canada Secretariat approval has been obtained

Date modified:: 2024-08-13

Residence (provide addresses for the last five years, starting with the most current).

Residence (provide addresses for the last 10 years, starting with the most current).

Criminal Convictions In and Outside of Canada

Current Spouse/Common-Law Partner

Previous Spouse / Common-Law Partners

Parents

Parents-in-laws

Children (children 18 years and over required)

Siblings

Neighbourhood Reference

Character Reference 1

Character Reference 2

Character Reference 3

Association with Persons Outside of Canada

Place of Residence (full address)

Affiliations to any Associations/Clubs or Groups

Personnel Screening, Consent and Authorization Form - Disclaimer

1. Administrative Information

2. Residency and Travel Outside of Canada

3. Biographical Information

Residence

Criminal Convictions In and Outside of Canada

4. Marital Status/Common-Law Partnership Information

5. Immediate Relatives Information

6. Citizenship Information

7. Employment Information

8. Travel Information

9. Character References in Canada

10. Education information

11. Military Information

12. Residency and Travel Outside of Canada Information

13. Consent and Verification