Organization Information Sheet
Industrial Security Program / Public Works and Government Services Canada

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Part A

Organization Number:

Legal Name of Organization

Business or Trade Names (if used)

Indicate the legal arrangement your organization uses to carry on business:

Corporation (Please provide a copy of the Certificate of Incorporation
Partnership (Please provide a copy of any registration documentation)
Sole Proprietorship (Please provide any registration documentation if applicable)
Other (Specify)

Phone Number

Fax Number

Procurement Business Number (BPN) if known

Web Address

Mailing Address

Mailing Address Street Number

Mailing Address Unit Number

Mailing Address Street Name

Mailing Address City

Mailing Address Province

Mailing Address Postal Code

Facility address

Same as Mailing Address

Facility address Street Number

Facility address Unit Number

Facility address Street Name

Facility address City

Facility address Province

Facility address Postal Code

Address of Head Office in Canada

Same as facility

Address of Head Office in Canada Street Number

Address of Head Office in Canada Unit Number

Address of Head Office in Canada Street Name

Address of Head Office in Canada City

Address of Head Office in Canada Province

Address of Head Office in Canada Postal Code

Part B

Does a Parent Organization Exist? (An entity that owns a majority of the corporation’s voting securities)

YES NO

If yes, please complete below and identify any Foreign Ownership in excess of 20%

Immediate Parent Organization ( ) % ownership of subsidiary organization

Immediate Parent Organization Street Number

Immediate Parent Organization Unit Number

Immediate Parent Organization Street Name

Immediate Parent Organization City

Immediate Parent Organization Province/State

Immediate Parent Organization Postal Code

Intermediate Parent Organization ( ) % ownership of immediate parent organization

Street Number

Unit Number

Street Name

City

Province/State

Postal Code

Ultimate Parent Organization ( ) % ownership of intermediate parent organization

Ultimate Parent Organization Street Number

Ultimate Parent Organization Unit Number

Ultimate Parent Organization Street Name

Ultimate Parent Organization City

Ultimate Parent Organization Province/State

Ultimate Parent Organization Postal Code

Part C

Please identify the name of the person(s) you wish to nominate as your organization’s Company Security Officer (CSO) and Alternate Company Security Officer (ACSO). Please include completed appointment forms, which have been provided along with this information sheet.

Part C. a. Position Title

Part C. a. Surname

Part C. a. Given Name

Part C. b. Position Title

Part C. b. Surname

Part C. b. Given Name

Part C. c. Position Title

Part C. c. Surname

Part C. c. Given Name

Part D

Key Senior Official(s): Identify the name and position of all owners, officers, directors (of the board), executives, and partners of the organization who occupy positions which may enable them to influence your organization's policies or practices in the performance of Protected/Classified contracts below.

Part D. a. Position Title

Part D. a. Surname

Part D. a. Given Name

Part D. b. Position Title

Part D. b. Surname

Part D. b. Given Name

Part D. c. Position Title

Part D. c. Surname

Part D. c. Given Name

Part D. d. Position Title

Part D. d. Surname

Part D. d. Given Name

Part D. e. Position Title

Part D. e. Surname

Part D. e. Given Name

Part D. f. Position Title

Part D. f. Surname

Part D. f. Given Name

Part D. g. Position Title

Part D. g. Surname

Part D. g. Given Name

Part D. h. Position Title

Part D. h. Surname

Part D. h. Given Name

Part D. i. Position Title

Part D. i. Surname

Part D. i. Given Name

Part D. j. Position Title

Part D. j. Surname

Part D. j. Given Name

Part E

I, the undersigned, as CSO acknowledge that all information contained within this form is complete and accurate.

Signature of CSO

Date (YYYY-MM-DD)

The below portion is to be completed by CISD:

ISR Initial Recommendation

ISR Initial Recommendation

ISR Initial Recommendation Signature

ISR Initial Recommendation Date (YYYY-MM-DD)

ISR Final Recommendation

ISR Final Recommendation

ISR Final Recommendation Signature

ISR Final Recommendation Date (YYYY-MM-DD)

Organization Information Sheet Industrial Security Program / Public Works and Government Services Canada