Public Works and Government Services Canada
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Owner, Authorized Individual, Designated Official, Officer, Director, Employee
8. Description of the controlled goods the applicant may be required to examine, possess or transfer (Refer to the Export Control List (ECL))
a.
b.
c.
d.
e.
9. Type of Application
10. Business Title (Select all that apply)
11. Preferred Language of Correspondence
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
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.
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.
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.
17. Home Address
18. Telephone Number(s)
19.
20. Other names used (Nicknames, aliases, etc.)
21. Indicate any change of name (Include former names, maiden name, etc.)
Born in Canada (if born outside Canada, go to No. 25)
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).
Born Outside Canada (For Canadians born outside Canada, if applicable, include Birth Abroad Certificate)
28. List all Citizenships (Country name)
33. List all places of residence during the last (5) years and include duration of stay, beginning with your current address. (Leave no gaps)
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.
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)
36. Have you been convicted of a criminal offence for which you have not been granted a pardon/record suspension?
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.
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.
39. List all valid passports currently in your possession and provide the following information.
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
Ex. 2
f.
g.
h.
i.
j.
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.
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)
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.).
If yes, provide details (city/town of residence, country and dates):
If yes, list the country and relationship:
If yes, provide name or organization and/or government and country:
If yes, provide details:
If yes, provide date and country of origin:
If yes, provide details, country, dates, etc.:
If yes, provide details on program of study, country and dates, etc.:
If yes, provide reason, country, dates, etc.:
If yes, provide date, to whom you surrendered your passport, location, reason(s) your passport was surrendered and the outcome:
If yes, provide company name, country and dates of employment:
If yes, provide name of country:
If yes, provide dates, nationality of government, government department and position(s) held:
If yes, list organization and country:
Please read the instructions carefully as they contain important information. Incomplete Security Assessment Applications will not be processed and will be returned to the addressee.
This form is to be completed by the Owner, Authorized Individual, Designated Official (DO), Officer, Director and Employee.
The Controlled Goods Program (CGP) will perform the security assessment of the Owner, Authorized Individual and DO who will be notified if the application has been approved or denied once the security assessment is completed.
The approved DO performs the security assessment of the Officer, Director and Employee accessing controlled goods.
Complete all sections. If a section is not applicable, indicate “N/A” in the space provided. If additional space is required, use an extra sheet of paper and attach it to the application. The first four pages also contain the information required for a Record Name Check and can be shared with law enforcement agencies and RCMP accredited agencies.
If you require assistance, please contact the CGP at 1-866-368-4646. Please ensure that you complete as much of the form as possible before calling and have a list of your questions ready for the CGP agent.
This section is to be completed by the DO where possible, or the proposed DO if no one has been previously security assessed and approved by CGP.
Please provide information concerning the business/operating/marketing name of the organization that is registered with the CG. If the legal name and the business name are the same, indicate “N/A” under Business Name.
In part 8, please provide a description of the controlled goods that you will examine, possess or transfer and indicate the Export Control List (ECL) group and item number(s). If you are having difficulty determining which ECL group you need to identify in this section, you should contact the organization with whom you have a contract or contact the Export Control Division at Foreign Affairs and International Trade Canada to obtain an Advisory Opinion. The description of the controlled goods should provide sufficient details so as to disclose the true identity of the goods. Avoid the use of trade names, generic names or general terms that do not adequately describe the goods.
Complete as requested.
C-1 This part refers to personal information under the control of a government institution and outlines the purpose for which the information was obtained, the authority for collection and its disclosure.
C-2 This part refers to personal information under the control of an organization. This part is optional and reserved for industry use only. It may be completed by the DO when conducting a security assessment of an Officer, Director and Employee of the registered person and include the details concerning the use and disclosure of personal information by the organization.
To be signed and dated by the Applicant.
Complete as requested. For any part of this section not applicable to you, please leave it blank.
In part 22, Permanent Resident has the same meaning as in subsection 2(1) of the Immigration and Refugee Act.
In part 26, Country of Provenance refers to the last country of residence before immigrating to Canada.
Complete as requested. Please note, if you have resided in a country other than Canada for a period of greater than 6 months within the past 5 years, you must obtain a Certificate of Good Conduct (or equivalent as the name varies by country) criminal records check (an FBI Criminal History Summary Check if resided in the United States of America) from that country. Please contact the country’s Canadian embassy, consulate or high commission for details on how to obtain this documentation.
Complete if applicable.
As part of the criminal record name check process, the applicant may be required to provide a full set of fingerprints, including both rolled and flat impressions of all 10 fingers. If you are required to provide fingerprints, you must have your fingerprints taken at your local police station or at a private accredited fingerprinting agency.
In part 39, if you do not hold a passport or have not travelled outside Canada, please indicate “N/A” in the ‘Country of Issuance’ box of row ‘a’.
In part 40, if you have not travelled outside of Canada or the United States within the past 5 years, please leave this section blank.
References must be non-family members (please note that in-laws and/or cohabitant(s) cannot be used as personal references). Examples are friends, business acquaintances, co-workers.
Include the following documentation:
Evidence to validate your eligibility
For Canadian citizens ordinarily resident in Canada, attach a copy of one (1) of the following as evidence of citizenship:
For permanent residents ordinarily resident in Canada, attach a copy of the following as evidence of your permanent resident status:
For evidence to validate your identity and residential address, attach a copy of the following:
For evidence to validate your employment history (if applicable), attach a copy of the following:
If applicable, for evidence to validate your educational history you must also provide the following documentation:
All applicants must also provide the following documentation:
Once the Designated Official and/or Owner and/or Authorized Individual have completed the application, please submit it via mail or courier:
Controlled Goods Program Public Works and Government Services Canada 2745 Iris Street, 3 rd Floor Ottawa ON K1A 0S5
Controlled Goods Program 2745 Iris Street, 3rd Floor c/o PWGSC Central Mail Room Place du Portage, Phase III, 0B3 11 Laurier Street Gatineau QC K1A 0S5
If desired, all required items associated with a Security Assessment Application for a Designated Official, Owner and Authorized Individual can be faxed or scanned and e-mailed (see below) in advance to the Controlled Goods Program. However, original mailed or couriered CPIC Criminal Record Name Checks, RCMP fingerprint reports and/or C216-C fingerprint forms are still mandatory.
613-948-1722
dmc-cgd@tpsgc-pwgsc.gc.ca
Please note: all security assessments conducted by the Designated Official are to be retained and securely stored by the Designated Official at a site belonging to the Registered Person.
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
