FORM 41

Security Intelligence Review Committee (SIRC)

SECTION A – PERSONAL INFORMATION

Title

Last Name

First Name

Address

Telephone number

Date of Birth

Email

Specific Allegations against the Canadian Security Intelligence Service (CSIS):

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You must first file a complaint by writing to the Director of CSIS at the following address:

Director
Canadian Security Intelligence Service
P.O. Box 9732
Postal Station T
Ottawa, ON K1G 4G4

If you are not satisfied with the Director’s response, or if you do not receive a response within a reasonable time (usually 30 days), you may then submit your complaint to SIRC.

You may contact SIRC at the following address:

Security Intelligence Review Committee
P.O. Box 2430
Station D
Ottawa, ON K1P 5W5

Once your complaint is received, SIRC will contact you to follow up on the information you provided. For further information, please contact the SIRC Registrar at 613-990-6319.

SECTION B – DETAILS OF MY COMPLAINT

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SECTION C – CERTIFICATION

□ I have sent a complaint letter to the Director of CSIS

□ I have attached a copy of my letter of complaint to the Director of CSIS

□ I am dissatisfied with the response from the Director of CSIS

□ I have not received a response from the Director of CSIS within 30 days

□ I have attached the response from the Director of CSIS, if any

Signature: _________________________________________

Date: _____________

Date modified: