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Security Clearance Fingerprint Third Party Consent to Release Personal Information

Cannabis Act

For the purpose of your security clearance application, a Canadian police force, the Royal Canadian Mounted Police (RCMP), or private fingerprinting agencies accredited by the RCMP can submit, on your behalf, your fingerprints electronically to the RCMP for the purpose of a criminal record check. The fees for taking electronic fingerprints vary and must be paid by the applicant at the time the service is performed.

I, (Print full name of the person applying for the security clearance)

require criminal record verification in order to obtain (Day) (Month) (Year)

a (Specify job title and name of applicant or licence holder [under the Cannabis Act)

I hereby authorize the RCMP central repository of criminal records to release my Criminal Records Fingerprint Verification results to the following party:

Health Canada AL: 0302F Ottawa, Ontario K1A 0K9

NOTE: To avoid any delays, an ink print MUST be placed in the box below in order for your prints to be processed in a timely manner. Please circle the finger used for the Biometric Consent.

DCN:

Applicant Signature:

Dated this day of , .

Right Thumb Left Thumb Right Index Left Index Right Middle Left Middle Right Ring Left Ring Right Small Left Small

2 | Security Clearance Fingerprint Third Party Consent to Release Personal Information

Important information and instructions for completion of Security Clearance Fingerprint Third Party Consent to Release Personal Information

Note: As part of the Application to become a Licence Holder under the Cannabis Act and its regulations and in the case of changes of personnel, a Security Clearance Application, including the security clearance applicant’s fingerprints must be submitted for all individuals that require a security clearance. All security clearance applicants must complete a Security Clearance Fingerprint Third Party Consent to Release Personal Information form, in accordance with the instructions below.

General:

1. This form is to be brought with the applicant to the local Police Station or RCMP private accredited fingerprintagency where their fingerprints will be taken.

2. This form must be completed in front of the person taking the fingerprints.3. It is very important that a single digit ink print be placed in the box on the form and the finger used identified by

circling the appropriate one next to the box. Failure to do so will result in delays.4. This form must be signed and dated by the applicant.5. This form must be submitted to the RCMP at the same time as fingerprints taken on *Form C-216C at your local

Police Station, RCMP or private accredited fingerprinting agency, accredited by the RCMP, whetherelectronically or by mail (in case of roll and ink prints).

*Form C-216C is the standard RCMP form used for fingerprinting• This form is not available online• You must have your fingerprints taken on Form C-216C at your local police station or private fingerprinting

agency accredited by the RCMP. Please see this link for a list of accredited private fingerprinting agencies• Depending on the police jurisdiction, a fee may be required