Industrial Security Program

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Request for Private Sector Organization Screening (PSOS) for a Canadian Organization

A – Type of Application (check one)

New

Upgrade

B – Information on Proposed Canadian Organization

1 – Legal name

2 – Business name (if different from legal name)

3 – Mailing address

4 – Facility address

5 – Organization telephone number

6 – Organization facsimile number

7 – Surname and given name of contact person (Canadian Official)

8 – Title of contact person

9 – Telephone number of contact person

10 – Email address of contact person

11 – Preferred language of correspondence (check one)

English

French

C – Information on Registered or Head Office in Canada (if different from above)

1 – Legal name

2 – Business name (if different from legal name)

3 – Facility address

D – Reason(s) for PSOS Request (check those that apply and provide details in space provided)

Contract/RFP, provide number

Subcontract, provide number

Program/Project, provide name

Major Crown Project, provide name

Other, provide details

E – Information on Security Requirements

1 – Indicate level(s) of personnel security screening required (check those that apply)

* RELIABILITY STATUS

CONFIDENTIAL

SECRET

TOP SECRET

NATO CONFIDENTIAL

NATO SECRET

COSMIC TOP SECRET

* This level is required for access to PROTECTED A, PROTECTED B AND PROTECTED C information or assets

2 – Will the proposed organization be required to store PROTECTED/CLASSIFIED information/assets?

Yes

A – If yes, indicate security level(s) of information/assets to be stored (check those that apply)* Also, provide address(es) where information/assets will be stored in sections B and C below.

PROTECTED A

PROTECTED B

PROTECTED C

CONFIDENTIAL

NATO SECRET

TOP SECRET

NATO CONFIDENTIAL

COSMIC TOP SECRET

*Please attach a completed Security Requirements Check List (SRCL)

B – Facility address

C – Facility address

3 – Additional information

F – Information on Procurement Officer / Project Manager Requesting PSOS (if different from G)

1 – Surname, given name

2 – Title/Rank

3 – Department/Agency/Organization

4 – Branch/Directorate

5 – Mailing address

6 – Email address

7 – Telephone number

8 – Facsimile number

9 – Signature of Approved Source

Signature

Date (YYYY-MM-DD)

G – Information on Approved Source proposing PSOS