INSTITUTIONAL ACCESS CPIC CLEARANCE REQUEST

PROTECTED B ONCE COMPLETED
INSTITUTIONAL ACCESS CPIC CLEARANCE REQUEST
PUT AWAY ON FILE
ADMINISTRATIVE OR OPERATIONAL FILE
Institution
A. PERSONAL INFORMATION
Surname
Full name (no nicknames or initials)
Maiden name (if applicable)
Date Of Birth (YYYY-MM-DD)
Place of birth City/Town
Province/State
Country
B. PHYSICAL DESCRIPTION
MaleFemale
Height
Weight
Eye color
Hair color
C. Address
Street
City or Town
Province
Postal Code
Telephone Number Home
Work
Representing (name of company/organization)
D. GENERAL INFORMATION
1. Have you ever been convicted of a criminal offence for which you have not been granted a pardon, or an offence for which you have been granted a pardon and such a pardon has been revoked?

YesNo
2. Do you personally know of any person incarcerated in a correctional facility.

YesNo
If yes, Provide names:
3. Do you have any reason to believe coming into contact with this person could pose a risk to your or their personal safety?

YesNo
4. Are you related/associated to an inmate or on an inmate's visiting list?

YesNo
If you have answered YES to any of the above, please explain below.
E. SIGNATURE (When sections A to E are filled out completely, please return the completed form to the institution for approval

In making this application, I hereby give the Correctional Service of Canada my consent to use the information provided on this form to conduct such inquiries with police authorities as may be necessary to ascertain my suitability. Finally, I acknowledge that the Correctional Service of Canada has no responsibility for any harm that may come to me in the course of my activities, except where such harm is a direct result of negligence on the part of an employee(s) of the Service. NOTE: Access may be denied for submitting false information. Passes may be issued for those receiving clearance and approval.
Applicant’s signature

Clear
Date (YYYY-MM-DD)

MonthDayYear
Date
Department making the request (please print)

An outstanding warrant/charge held by:
SIGNATURES
The individual has been advised. YesNo Date

CSC/SCC 1279E (R-2019-03) Personal information will be protected under the provisions of the Privacy (Word Version)Act and will be stored in Personal Information Bank CSC PPU 080.
DISTRIBUTION
Should be Empty:

PROTECTED B ONCE COMPLETED

INSTITUTIONAL ACCESS CPIC CLEARANCE REQUEST

PUT AWAY ON FILE

A. PERSONAL INFORMATION

B. PHYSICAL DESCRIPTION

C. Address

D. GENERAL INFORMATION

SIGNATURES

DISTRIBUTION