Security Clearance Fingerprint Third Party Consent to Release Personal Information - Marihuana for Medical Purposes Regulation (MMPR)

A Canadian police force, the Royal Canadian Mounted Police (RCMP), or private fingerprinting agencies accredited by the RCMP can submit your fingerprints electronically to the RCMP on your behalf. The fees for electronic fingerprint submission vary and must be paid by the applicant at the time the service is performed.

• I, (Please print full Name of the person applying for a security clearance)
• Born, (Day), (Month), (Year) require criminal record verification in order to obtain
  
• a (Specify job title and Name of Licensed Producer Applicant (corporation and individual) under the MMPR)

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

Health Canada
200 Eglantine Driveway
Ottawa, Ontario
K1A 0K9
A/L: 1912A1

I understand that I have the right to receive the results directly from the RCMP and that the assistance of a 3^rd party is not necessary to obtain these results.

I have read and signed this Informed Consent document and understand my rights with regard to obtaining criminal record information.

• 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.
  • Right Thumb
  • Left Thumb
  • Right Index
  • Left Index
  • Right Middle
  • Left Middle
  • Right Ring
  • Left Ring
  • Right Pinkie
  • Left Pinkie
    
• Applicant Signature
• Dated this ( ) day of ( ) , ( )

Important information and instructions for completion of Security Clearance Fingerprint Third Party Consent to Release Personal Information form under the Marihuana for Medical Purposes Regulations (MMPR) follow.

Note: As part of the Application to become a Licensed Producer under the Marihuana for Medical Purposes Regulations a Security Clearance Fingerprint Check must be conducted for all parties identified in the application. This includes applicants that apply as individual, a proposed senior person in charge, a proposed responsible person in charge, and a proposed alternate person in charge. In the case of a corporation, each Director and Officer of the corporation must also submit fingerprints and a duly completed Security Clearance Fingerprint Third Party Consent to Release Personal Information form.

A Canadian police force, the Royal Canadian Mounted Police (RCMP) or private fingerprinting agencies accredited by the RCMP submit your fingerprints electronically to the RCMP on your behalf. The fees for electronic fingerprint submission vary and must be paid by the applicant at the time the service is performed.

General:

1. This form is to be brought with the applicant to the local Police Station or RCMP private accredited fingerprint agency 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, whether electronically or by mail (in case of roll and ink prints).