NOTIFICATION OF SECURITY CLEARANCE
Department or Designate Security Officer Date (Y/M/D)
Reasons and comments (include attachments if applicable)
Department >
TO FROM
EFFECTIVE DATE (Y/M/D)
>
Our File No.
Given name(s)
CSIS file no.
Family name
PROTECTED (when completed)
Bank number : SIS PPU 005
CSIS/SCRS 4195e (2011/12/29)
Level I
Level II Level III
D.O.B. (Y/M/D)
CSIS
P.O. Box 9732, Postal Station T
Ottawa, Ontario
K1G 4G4
As per the Policy on Government Security, please be advised of the security clearance of the following individual:
The final decision as to whether to grant a Security Clearance rests with the Department. Your Department must conduct its own
internal investigation to determine if a revocation of reliability status is warranted. Please ensure that form 4195 is filled out upon
reaching your decision and return to CSIS. Should you wish to discuss this case further with us, please contact Security Screening
Branch to schedule meeting.
Client number>
Attention
Security Screening Branch - Client Liaison
Site Access
Granted
Revoked
Denied
