FORM 42

Security Intelligence Review Committee (SIRC)

SECTION A – PERSONAL INFORMATION

Title

Last Name

First Name

Address

Telephone number

Date of Birth

Email

Department or Deputy Head responsible for the Denial of my Security Clearance

If your security clearance was denied or revoked, the CSIS Act provides that the deputy head of the federal department or agency where you were employed or were seeking employment must advise you in writing within 10 days of making that decision. Once you receive this notice, you have 30 days to file a complaint with 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 HOW THE CLEARANCE DENIAL HAS LED TO A DENIAL OF EMPLOYMENT, A DISMISSAL, A DEMOTION OR A TRANSFER

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

SECTION C – CERTIFICATION

□ I am submitting this complaint within 30 days of receipt of the letter by the institution

If not:

Here are the reasons why the complaint was not submitted within 30 days:

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

□ I am enclosing a copy of the denial or revocation of security clearance letter received from the Deputy Head

Signature: ___________________________________________

Date: ________________

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