CONTROLLED GOODS PROGRAM
SECURITY ASSESSMENT APPLICATION

PDF Version (203Kb) Help on Alternative Formats

PROTECTED "B" when completed

Registration No.

Applicant's Name

Owner, Authorized Individual, Designated Official, Officer, Director, Employee

A. BUSINESS INFORMATION (To be completed by the Designated Official)

1. Legal Name

2. Business Name (If different from legal name)

3. Civic Address

4. Mailing Address (If different from civic address)

5. Telephone Number (Include extension no. if applicable)

6. Facsimile Number

7. E-mail

8. Description of the controlled goods the applicant may be required to examine, possess or transfer
(Refer to the Export Control List (ECL))

8. a. Description of Controlled Goods

8. a. ECL Group No.

8. a. ECL Item No.

8. b. Description of Controlled Goods

8. b. ECL Group No.

8. b. ECL Item No.

8. c. Description of Controlled Goods

8. c. ECL Group No.

8. c. ECL Item No.

8. d. Description of Controlled Goods

8. d. ECL Group No.

8. d. ECL Item No.

8. e. Description of Controlled Goods

8. e. ECL Group No.

8. e. ECL Item No.

B. APPLICANT INFORMATION (To be completed by the applicant)

9. Type of Application

New Re-Assessment

10. Business Title (Select all that apply)

Owner

Authorized Individual

Designated Official

Officer

Director

Employee

11. Preferred Language of Correspondence

English French

C. PRIVACY NOTICE

C-1 Personal Information Under the Control of a Government Institution

Your personal information requested is pursuant to section 38 of the Defence Production Act (DPA), and section 15 of the Controlled Goods Regulations (CGR) for the purpose of assessing security risks associated with controlled goods. The personal information is described in PIB PWGSC PPU 045 Controlled Goods Program. This information may also be used or disclosed for enforcement, safety, security, registration and evaluation. As part of the security assessment, personal information may be used or disclosed to:

The Canadian Industrial Security Program, PWGSC - name, birth date, and other identifier if required to confirm a valid security clearance (as reported in Section M);
The Credit Bureau(s) - name, birth date and contact information to establish financial risk;
The Royal Canadian Mounted Police (RCMP) - all information on this form to conduct a criminal check/history; and
The Canadian Security Intelligence Service (CSIS) - all information on this form to conduct a national security threat check.

Refusal to provide personal information will result in your being prohibited from examining, possessing or transferring controlled goods as defined in subsection 37(1) of the DPA.

Your personal information is protected under the Privacy Act and will only be used and disclosed in accordance with the Act. You have the right to access and correct your personal information if erroneous or incomplete.

FOR INDUSTRY USE ONLY

C-2 Personal Information Under the Control of an Organization (for optional use by the Designated Official)

D. CONSENT

I, the undersigned, have read the privacy notice above and consent to the collection, use and disclosure of my personal information for the purposes as described in C-1 and C-2.

Applicant's Signature

Date (YYYY-MM-DD)

Print Name

INSTRUCTIONS

WARNING:

Any false or misleading statement on this form or relating to any document in support of this application, including concealment of any material fact, may lead to the refusal of access to controlled goods or the denial or revocation of registration with the Controlled Goods Program and be grounds for criminal prosecution under section 44 of the Defence Production Act.

Failure to complete all required sections of this form may result in your application being rejected.

The information requested is in respect of the five (5) year period immediately preceding the date of this security assessment application.

E. BIOGRAPHICAL INFORMATION

Attach two pieces of government-issued identification that provides proof of Citizenship or permanent residency (i.e. Birth certificate, Passport, Permanent Resident Card, etc.) and proof of residence (i.e. Driver's Licence, Government-issued Document with Address, etc.). One of which must be photo identification.

12. Surname

13. Full Given Name(s)
(No initials, underline usual name used)

14. Surname at Birth

15. Gender

Male Female

16. Date of Birth (YYYY-MM-DD)

17. Home Address

Number and Street

Apt. Number

City

Province/Territory

Country

Postal Code

18. Telephone Number(s)

Home

Work (Include extension no. if applicable)

Mobile

19.

20. Other names used (Nicknames, aliases, etc.)

21. Indicate any change of name (Include former names, maiden name, etc.)

21. a. From Surname - Given Name

21. a. To Surname - Given Name

21. a. Date of change (YYYY-MM-DD)

21. b. From Surname - Given Name

21. b. To Surname - Given Name

21. b. Date of change (YYYY-MM-DD)

F. COUNTRY OF ORIGIN

22. Current Status

Canadian Citizen Permanent Resident

Born in Canada (if born outside Canada, go to no. 25)

23. Birth Certificate Number

24. City and Province/Territory of Birth
(If you hold citizenship with another country, go to no. 28. If not applicable, go to section G).

24. City

24. Province/Territory

Born Outside Canada (For Canadians born outside Canada, if applicable, include Birth Abroad Certificate)

25. City and Country of Birth

26. Country of Provenance

27. Date of Entry into
Canada (YYYY-MM-DD)

28. List all Citizenships (Country name)

28. a

28. b

28. c

28. d

29. Permanent Resident
Certificate Number (If applicable)

30. Date of Issue (YYYY-MM-DD)

31. Naturalized Canadian Certificate Number (If applicable)

32. Date of Issue (YYYY-MM-DD)

G. RESIDENTIAL HISTORY

33. List all places of residence during the last (5) years and include duration of stay, beginning with your current address. (Leave no gaps)

33. a. Street No.

33. a. Street Name

33. a. Apt. No.

33. a. City

33. a. Province/Territory

33. a. Country

33. a. Postal Code

33. a. Date From (YYYY-MM)

33. a. Date To (YYYY-MM)

33. b. Street No.

33. b. Street Name

33. b. Apt. No.

33. b. City

33. b. Province/Territory

33. b. Country

33. b. Postal Code

33. b. Date From (YYYY-MM)

33. b. Date To (YYYY-MM)

33. c. Street No.

33. c. Street Name

33. c. Apt. No.

33. c. City

33. c. Province/Territory

33. c. Country

33. c. Postal Code

33. c. Date From (YYYY-MM)

33. c. Date To (YYYY-MM)

33. d. Street No.

33. d. Street Name

33. d. Apt. No.

33. d. City

33. d. Province/Territory

33. d. Country

33. d. Postal Code

33. d. Date From (YYYY-MM)

33. d. Date To (YYYY-MM)

33. e. Street No.

33. e. Street Name

33. e. Apt. No.

33. e. City

33. e. Province/Territory

33. e. Country

33. e. Postal Code

33. e. Date From (YYYY-MM)

33. e. Date To (YYYY-MM)

H. EDUCATIONAL HISTORY (If applicable)

34. List all domestic and foreign educational institutions attended during the last five (5) years and all fields of study, beginning with the most recent, and include the duration of study.

34. a. School/Institution

34. a. Field of Study

34. a. Full Civic Address

34. a. Date From (YYYY-MM)

34. a. Date To (YYYY-MM)

34. b. School/Institution

34. b. Field of Study

34. b. Full Civic Address

34. b. Date From (YYYY-MM)

34. b. Date To (YYYY-MM)

34. c. School/Institution

34. c. Field of Study

34. c. Full Civic Address

34. c. Date From (YYYY-MM)

34. c. Date To (YYYY-MM)

I. EMPLOYMENT HISTORY

35. List all domestic and foreign employment activities during the last five (5) years including full-time, part-time, temporary and self-employment, and periods of unemployment, beginning with the most recent. (Leave no gaps)

35. a. Employer

35. a. Position Title

35. a. Full Civic Address

35. a. Date From (YYYY-MM)

35. a. Date To (YYYY-MM)

35. b. Employer

35. b. Position Title

35. b. Full Civic Address

35. b. Date From (YYYY-MM)

35. b. Date To (YYYY-MM)

35. c. Employer

35. c. Position Title

35. c. Full Civic Address

35. c. Date From (YYYY-MM)

35. c. Date To (YYYY-MM)

35. d. Employer

35. d. Position Title

35. d. Full Civic Address

35. d. Date From (YYYY-MM)

35. d. Date To (YYYY-MM)

35. e. Employer

35. e. Position Title

35. e. Full Civic Address

35. e. Date From (YYYY-MM)

35. e. Date To (YYYY-MM)

J. CRIMINAL HISTORY

36. Have you been convicted of a criminal offence for which you have not been granted a pardon/record suspension?

Yes No (If you answer "No", go to 38)

37. If in the past five (5) years, you have been convicted of a criminal offence in any country, including Canada, for which you have not been granted a pardon/record suspension, provide the following information.

37. a. Charges

37. a. Police

37. a. City

37. a. Province/Territory

37. a. Country

37. a. Date (YYYY-MM)

37. a. Full Name at Time of Conviction

37. b. Charges

37. b. Police

37. b. City

37. b. Province/Territory

37. b. Country

37. b. Date (YYYY-MM)

37. b. Full Name at Time of Conviction

37. c. Charges

37. c. Police

37. c. City

37. c. Province/Territory

37. c. Country

37. c. Date (YYYY-MM)

37. c. Full Name at Time of Conviction

38. If in the past five (5) years you have been detained, arrested or the subject of a criminal action in any country, including Canada, specify the occurrence and provide the following information.

38. a. Occurrence

38. a. Details/Reasons

38. a. City

38. a. Province/Territory

38. a. Country

38. a. Date (YYYY-MM)

38. a. Status

38. b. Occurrence

38. b. Details/Reasons

38. b. City

38. b. Province/Territory

38. b. Country

38. b. Date (YYYY-MM)

38. b. Status

38. c. Occurrence

38. c. Details/Reasons

38. c. City

38. c. Province/Territory

38. c. Country

38. c. Date (YYYY-MM)

38. c. Status

K. TRAVEL HISTORY

39. List all valid passports currently in your possession and provide the following information.

39. a. Country of Issuance

39. a. Passport No.

39. a. Date of Issuance (YYYY-MM)

39. a. Name on Passport

39. a. Expiry Date (YYYY-MM)

39. b. Country of Issuance

39. b. Passport No.

39. b. Date of Issuance (YYYY-MM)

39. b. Name on Passport

39. b. Expiry Date (YYYY-MM)

40. If during the last five (5) years you have travelled to countries other than the United States of America, provide the following information. (If you travel frequently you may group the travel per country per timeframe).

Ex. 1

40. Ex. 1 Country

40. Ex. 1 No. of Visits

40. Ex. 1 Date From (YYYY-MM)

40. Ex. 1 Date To (YYYY-MM)

40. Ex. 1 Total Weeks Spent (If less than 1 week, enter 1)

40. Ex. 1 Purpose (Business or Pleasure)

Purpose (Business or Pleasure)

Business Pleasure

Ex. 2

40. Ex. 2 Country

40. Ex. 2 No. of Visits

40. Ex. 2 Date From (YYYY-MM)

40. Ex. 2 Date To (YYYY-MM)

40. Ex. 2 Total Weeks Spent (If less than 1 week, enter 1)

40. Ex. 2 Purpose (Business or Pleasure)

Purpose (Business or Pleasure)

Business Pleasure

40. a. Country

40. a. No. of Visits

40. a. Date From (YYYY-MM)

40. a. Date To (YYYY-MM)

40. a. Total Weeks Spent (If less than 1 week, enter 1)

40 a. Purpose (Business or Pleasure)

Purpose (Business or Pleasure)

Business Pleasure

40. b. Country

40. b. No. of Visits

40. b. Date From (YYYY-MM)

40. b. Date To (YYYY-MM)

40. b. Total Weeks Spent (If less than 1 week, enter 1)

40 b. Purpose (Business or Pleasure)

Purpose (Business or Pleasure)

Business Pleasure

40. c. Country

40. c. No. of Visits

40. c. Date From (YYYY-MM)

40. c. Date To (YYYY-MM)

40. c. Total Weeks Spent (If less than 1 week, enter 1)

40. c. Purpose (Business or Pleasure)

Purpose (Business or Pleasure)

Business Pleasure

40. d. Country

40. d. No. of Visits

40. d. Date From (YYYY-MM)

40. d. Date To (YYYY-MM)

40. d. Total Weeks Spent (If less than 1 week, enter 1)

40. d. Purpose (Business or Pleasure)

Purpose (Business or Pleasure)

Business Pleasure

40. e. Country

40. e. No. of Visits

40. e. Date From (YYYY-MM)

40. e. Date To (YYYY-MM)

40. e. Total Weeks Spent (If less than 1 week, enter 1)

40. e. Purpose (Business or Pleasure)

Purpose (Business or Pleasure)

Business Pleasure

40. f. Country

40. f. No. of Visits

40. f. Date From (YYYY-MM)

40. f. Date To (YYYY-MM)

40. f. Total Weeks Spent (If less than 1 week, enter 1)

40. f. Purpose (Business or Pleasure)

Purpose (Business or Pleasure)

Business Pleasure

40. g. Country

40. g. No. of Visits

40. g. Date From (YYYY-MM)

40. g. Date To (YYYY-MM)

40. g. Total Weeks Spent (If less than 1 week, enter 1)

40. g. Purpose (Business or Pleasure)

Purpose (Business or Pleasure)

Business Pleasure

40. h. Country

40. h. No. of Visits

40. h. Date From (YYYY-MM)

40. h. Date To (YYYY-MM)

40. h. Total Weeks Spent (If less than 1 week, enter 1)

40. h. Purpose (Business or Pleasure)

Purpose (Business or Pleasure)

Business Pleasure

40. i. Country

40. i. No. of Visits

40. i. Date From (YYYY-MM)

40. i. Date To (YYYY-MM)

40. i. Total Weeks Spent (If less than 1 week, enter 1)

40. i. Purpose (Business or Pleasure)

Purpose (Business or Pleasure)

Business Pleasure

40. j. Country

40. j. No. of Visits

40. j. Date From (YYYY-MM)

40. j. Date To (YYYY-MM)

40. j. Total Weeks Spent (If less than 1 week, enter 1)

40. j. Purpose (Business or Pleasure)

Purpose (Business or Pleasure)

Business Pleasure

L. PERSONAL REFERENCES

41. Provide the following information for three people who have known you personally for at least five (5) years that can confirm the information in your application. Family members, in-laws and co-habitants cannot be used as personal references.

41. a. Surname, Given Name

41. a. Relationship

41. a. Has known me since (State year)

41. a. Home Telephone Number

41. a. Daytime Telephone Number

41. a. Home Address (Including House and/or Apt. No., Street, City, Province/Territory and Postal Code)

41. b. Surname, Given Name

41. b. Relationship

41. b. Has known me since (State year)

41. b. Home Telephone Number

41. b. Daytime Telephone Number

41. b. Home Address (Including House and/or Apt. No., Street, City, Province/Territory and Postal Code)

41. c. Surname, Given Name

41. c. Relationship

41. c. Has known me since (State year)

41. c. Home Telephone Number

41. c. Daytime Telephone Number

41. c. Home Address (Including House and/or Apt. No., Street, City, Province/Territory and Postal Code)

M. SECURITY CLEARANCE

42. If you possess a valid security clearance, indicate the level, the country of issuance, the issuing government department and the expiry date. (Select all that apply)

Confidential
Secret
Top Secret
Secret NATO
Other (Specify)

43. Country of Issuance

44. Issuing Government Department

45. Expiry Date (YYYY-MM-DD)

N. SECURITY ASSESSMENT STATEMENTS

In Part N of this application, your answers need not mention a country that the Contolled Goods Directorate (CGD) considers to have a program that is equivalent to the Controlled Goods Program (CGP) in terms of preventing the risk of diversion of controlled goods. Currently, the CGD considers only the program administered by the United States of America's Directorate of Defence Trade Controls to be equivalent to the CGP. This means that your answers need not reference the U.S.A. (i.e. travel to the U.S.A.; residences owned in the U.S.A., etc.).

The information requested is in respect of the five (5) year period immediately preceding the date of this security assessment application.

1. I hold a valid passport of a country other than Canada (excluding the United States).

Yes No

2. I have travelled outside Canada for pleasure, more than 10 times in the last five years (excluding the United States).

Yes No

3. I have travelled outside Canada for business (excluding the United States).

Yes No

4. I have resided outside Canada (excluding the United States).

Yes No

If yes, provide details (city/town of residence, country and dates):

5. I have immediate family members that reside in a country outside Canada (excluding the United States).

5. I have immediate family members^{Footnote 1} that reside in a country outside Canada (excluding the United States).

Yes No

If yes, list the country and relationship:

6. I received financial support from an organization or government agency outside of Canada for my education (excluding the United States).

Yes No

If yes, provide name or organization and/or government and country:

7. I own or have partial ownership (20% or more voting shares) in a business or company outside Canada (excluding the United States).

Yes No

If yes, provide details:

8. I have had contact, meetings, business or social activities, with foreign officials, excluding individuals from the United States (i.e.: non-Canadian government/department/embassy).

Yes No

If yes, provide details:

9. I have sponsored a foreign individual for entry into Canada.

Yes No

If yes, provide date and country of origin:

10. I have travelled outside Canada for a period greater than 90 consecutive days (excluding the United States).

Yes No

If yes, provide details, country, dates, etc.:

11. I received my education outside of Canada (excluding the United States).

Yes No

If yes, provide details on program of study, country and dates, etc.:

12. I have previously been denied entry into a country.

Yes No

If yes, provide reason, country, dates, etc.:

13. I have previously been ordered to surrender my passport to a government official (i.e.: customs, police, passport agency or similar).

Yes No

If yes, provide date, to whom you surrendered your passport, location, reason(s) your passport was surrendered and the outcome:

14. I have worked for a company located in a foreign country (excluding the United States).

Yes No

If yes, provide company name, country and dates of employment:

15. I consider myself to have allegiance to a country other than Canada or the United States.

Yes No

If yes, provide name of country:

16. I have worked for a foreign government, including military service (excluding the United States).

Yes No

If yes, provide dates, nationality of government, government department and position(s) held:

17. I have served in a security/intelligence organization in a country other than Canada (excluding the United States).

Yes No

If yes, list organization and country:

8. I have previously had a security clearance denied, suspended or revoked.

18. I have previously had a security clearance denied, suspended or revoked.

Yes No

If yes, provide details:

19. I have meaningful associations with an individual(s), who is a member of, or is a supporter of, a group involved in espionage, terrorism, organized crime, subversive or militant activities.

Yes No

20. I have been terminated or asked to resign from a position due to a theft or fraud related incident(s).

Yes No

21. I have previously filed bankruptcy.

Yes No

22. I currently have a financial judgement against me (this includes a fine or restitution regardless of whether you are in arrears; or any other type of financial judgement e.g. child support, taxes in which you are in arrears more than three months).

Yes No

23. I have previously been denied credit and/or had my credit card revoked.

Yes No

If yes, provide details:

Footnote 1

Immediate Family Members: spouse or common-law partner, father (including step), mother (including step), parents-in-law (including step and common-law), children (including step and adopted and children of common-law partner), and siblings (including step and adopted).

Return to footnote 1 referrer

CONTROLLED GOODS PROGRAM SECURITY ASSESSMENT APPLICATION

A. BUSINESS INFORMATION (To be completed by the Designated Official)

B. APPLICANT INFORMATION (To be completed by the applicant)

C. PRIVACY NOTICE

C-1 Personal Information Under the Control of a Government Institution

C-2 Personal Information Under the Control of an Organization (for optional use by the Designated Official)

D. CONSENT

E. BIOGRAPHICAL INFORMATION

F. COUNTRY OF ORIGIN

G. RESIDENTIAL HISTORY

H. EDUCATIONAL HISTORY (If applicable)

I. EMPLOYMENT HISTORY

J. CRIMINAL HISTORY

K. TRAVEL HISTORY

L. PERSONAL REFERENCES

M. SECURITY CLEARANCE

N. SECURITY ASSESSMENT STATEMENTS

CONTROLLED GOODS PROGRAM
SECURITY ASSESSMENT APPLICATION