CANADA BORDER SERVICES AGENCY PROTECTED B

(once completed)
Applicant Name: _____________________
(Print)
- 1 1


INTEGRITY QUESTIONNAIRE

The information collected in this form is personal.

The Canada Border Services Agency (CBSA) is responsible for providing integrated
border services that support national security and public safety priorities and facilitate
the free flow of persons and goods into Canada.

To fulfill this mission, employees of the CBSA must conduct themselves with integrity,
respect and professionalism. It is imperative, therefore, that the CBSA carefully assess
the integrity of new applicants and current employees. To facilitate such an assessment,
the CBSA has developed the following Integrity Questionnaire.


Applicant Surname Applicant Given Name(s)


Mailing Address (Street address, city, province, postal code) Telephone No. 1



E-Mail Address Telephone No. 2




Le prsent formulaire est galement disponible en franais, sur demande et au
http://cbsa-asfc.gc.ca/job-emploi/bso-asf/iq-qi-fra.pdf



FOR OFFICE USE ONLY

Form # Applicant ID No.

Name of Reviewer Signature Date Review Completed














CANADA BORDER SERVICES AGENCY PROTECTED B
(once completed)
Applicant Name: _____________________
(Print)
- 2 2
Before writing answers to the questions contained in this Integrity Questionnaire, Applicants are
advised to:
-carefully read the information and notices on Pages 2, 3, 4 and 5;
-read, initial and sign the Declaration, Acknowledgment, and Consent on Page 5;
-follow the instructions listed on Page 6.

NOTICE REGARDING THE COLLECTION AND USE OF PERSONAL INFORMATION

The information you provide in this document is collected under the authority of the
Financial Administration Act (FAA) sections 7(1), 11.1(1) and 12(1)(e), Sections 5
and 11 of the Canada Border Services Agency Act, Section 31 of the Public Service
Employment Act and the Policy on Government Security. It is collected for the
purposes of providing a security screening assessment, for the reliability status, security
clearance or site access of individuals working or applying to work through appointment,
assignment or contract at the Canada Border Services Agency. The information may be
disclosed to the Canadian Security Intelligence Service (CSIS) and the Royal Canadian
Mounted Police (RCMP) as service providers in accordance with the Policy on
Government Security. The security screening status may be shared within the Canada
Border Services Agency to update individual's personnel file. nformation may also be
shared with entities outside the Federal Government, including credit bureaus for the
purposes of conducting reliability personnel security screening checks, conducting
database checks, audit, statistical, periodic data matching and to assess an individual's
loyalty and reliability as it relates to loyalty. The information may be used by accredited
domestic law enforcement agencies in the administration or enforcement of the law and
in the detection, prevention or suppression of a crime.

The information provided in the Integrity Questionnaire will be retained by the CBSA for
a minimum of two years and may be used to determine your suitability and reliability,
and to conduct a security assessment for any other position within the CBSA to which
you may apply. This may result in your disqualification from that other hiring process.

Individuals have the right of access to, the protection and correction of their personal
information under the Privacy Act. The information collected is described under the
Personnel Security Screening Program Personal Information Bank CBSA PPU
1108 which is detailed at www.infosource.gc.ca.

'I, the undersigned, do consent to the disclosure of the preceding information
including my photograph for its subsequent verification and/or use in an
investigation for the purpose of providing a security screening assessment. By
consenting to the above, I acknowledge that the verification and/or use in an
investigation of the preceding information may also occur when the reliability
status, security clearance or site access are updated or otherwise reviewed for
cause under the Policy on Government Security.
My consent will remain valid until such time as any such reliability status, security
clearance or site access clearance is no longer a requirement for my continued
employment with the CBSA, or any successor thereto, my employment is
terminated, I am deployed to a position with another employer within the
Government of Canada, or I revoke my consent, in writing, to the Director General,
Security and Professional Standards of the Agency."


CANADA BORDER SERVICES AGENCY PROTECTED B
(once completed)
Applicant Name: _____________________
(Print)
- 3 3

NOTICE REGARDING THE INTEGRITY QUESTIONNAIRE

Your decision to complete the Integrity Questionnaire must be voluntary, based on your
desire to pursue a career with the CBSA.

You may withdraw from the application process at any time. You may refuse to provide
answers to any or all of the questions contained in the Integrity Questionnaire. Such a
refusal may result in your disqualification from the recruitment process.

You should answer the questions contained in the Integrity Questionnaire accurately,
completely, thoroughly, and honestly to the best of your knowledge and belief. An
incomplete Integrity Questionnaire may result in your disqualification from the
recruitment process.

You are not required to provide any information in the Integrity Questionnaire that
relates to a conviction for which a pardon has been received or a conviction that was
processed pursuant to the Young Offenders Act (R.S.C. 1985, c. Y-1, now repealed) or
the Youth Criminal Justice Act (S.C., 2002, c.1).

Should there be a change in circumstances, after your submission of the Integrity
Questionnaire, which would require that you amend any of the responses made in the
Integrity Questionnaire for it to be complete and accurate, you should contact the
Recruitment Officer.

Deceit, dishonesty, or non-disclosure in any part of the application process is likely to
result in your disqualification from the recruitment process and/or any future employment
with the CBSA.

If you are currently employed by, or working for the CBSA, the information provided in
the Integrity Questionnaire may be used to determine your suitability and reliability, and
for security screening purposes. This may result in your disqualification from the
employment process in question. This may also lead to, where applicable, the imposition
of discipline, the revocation of an existing reliability status/security screening level,
and/or possible dismissal from current employment.















CANADA BORDER SERVICES AGENCY PROTECTED B
(once completed)
Applicant Name: _____________________
(Print)
- 4 4
NOTICE REGARDING MISCONDUCT, CRIMINAL OFFENCES
AND RISK TO THE SAFETY OF OTHERS

The information you provide during the recruitment process is collected by the CBSA for
the purposes of an employment application, and security screening. All answers which
reveal criminal activity may be disclosed to the RCMP and CSIS as part of the security
screening process.

If you admit to having committed one or a number of criminal offence(s), for which a
pardon was not obtained, on the Integrity Questionnaire or during the Integrity Interview,
be advised that the information may be disclosed to entities with lawful authority to
collect such information (e.g. police of jurisdiction or child protection agency).

If, in light of the information provided throughout the screening process, you are deemed
to pose a threat to others, be advised that the information may be disclosed to entities
with lawful authority to collect such information (e.g. police of jurisdiction).

You are also advised that such disclosures could lead to incident reports being entered
into police databases, which could impact future employment or volunteering
opportunities, or other activities that require security screening (e.g. employment with
schools, banks, etc.).

Such disclosures could also lead to an investigation, arrest, charge(s), criminal
prosecution, conviction, and, ultimately, imposition of a sentence.


CANADA BORDER SERVICES AGENCY PROTECTED B
(once completed)
Applicant Name: _____________________
(Print)
- 5 5
DECLARATION, ACKNOWLEDGMENT, AND CONSENT

Should you have any questions concerning what you have read in the preceding pages,
please contact your Recruitment Officer to clarify before proceeding any further.

Please ensure that you initial each of the following statements in the space provided:

Applicant Initials

I, the undersigned, have read and understand the information and notices on
Pages 1, 2, 3 and 4 of this Integrity Questionnaire.


I complete this Integrity Questionnaire voluntarily, based on my desire to pursue a
career with the CBSA.


I declare that I will provide, in this Integrity Questionnaire, information that is up-to-
date, accurate, complete and honest, to the best of my knowledge and belief.


I understand that there is a possibility that I may amend my answer(s) to any
question (s) in the Integrity Questionnaire by contacting the Recruitment Officer.


I understand that I do not have to include any information in this Integrity
Questionnaire that relates to a conviction for which a pardon has been received,
or a conviction that was processed pursuant to the Young Offender's Act or the
Youth Criminal Justice Act.


I understand that the information provided in this Integrity Questionnaire may
affect my possibilities for any other employment with, or at, the CBSA within the
next two (2) years, and/or, where applicable, may affect my current employment
with, or work at, the CBSA.


I understand that if I admit to having committed one or a number of criminal
offence(s), in this Integrity Questionnaire or during the Integrity Interview, actions
could be taken which could lead, ultimately, to the imposition of a sentence.


I consent to my personal information being collected, used, and disclosed for the
purposes identified on the foregoing Pages 2, 3, 4 and 5 of this Integrity
Questionnaire.


I consent to my personal information being used for security screening pursuant to
the Treasury Board Policy on Government Security (www.tbs-sct.gc.ca).





_____________________________________
Name of Applicant (print)



____________________________________ _____________________
Signature of Applicant Date





CANADA BORDER SERVICES AGENCY PROTECTED B
(once completed)
Applicant Name: _____________________
(Print)
- 6 6
Please read and follow these instructions for Completion of the Integrity
Questionnaire carefully
General:

1. Once completed by the Applicant and received by the CBSA, this Questionnaire will be
safeguarded and handled by the CBSA at the level of "Protected B.

2. Considering the personal and sensitive nature of the information to be provided, you should
complete the Questionnaire in private, on your own, and without the assistance of a third
party (e.g. family member(s) or friend(s)).

3. The Questionnaire must be completed clearly and legibly. It can be filled out on-line or, if
handwritten, it must be in black ink. Illegible forms will be returned for clarification and will
potentially slow down the recruitment process.

4. Answer the questions accurately, completely, and thoroughly by providing information that is up to
date and honest to the best of your knowledge and belief. An incomplete Integrity Questionnaire
may result in your disqualification from the recruitment process.

5. Once the completed Questionnaire is received by the Recruitment Officer, it will be reviewed. The
Recruitment Office and/or the CBSA Personnel Security Screening Office may contact you to seek
additional information or clarify your answers to the questions contained in the Integrity
Questionnaire.

6. You may amend your answer(s) to any question(s) contained in the Integrity Questionnaire, by
contacting the Recruitment Office.


Detailed Instructions:

7. Complete this Integrity Questionnaire only if you are responding of your own free will and
understand that you may stop the process at any time.

8. All applicants must complete Sections A to L (questions 1 to 57). Follow instructions at the start of
each section, and read each question carefully.

9. If the space allotted for any question is insufficient, use the back of the corresponding sheet, and
identify the answer by referring to the section and number.

10. In your answers provide details stating whether the incidents or situations occurred in Canada or in
another country.

11. You are under no obligation to disclose any information regarding a crime where you were a
victim.

12. You are not obligated to include any information that relates to a conviction for which a pardon has
been received, or a conviction that was processed by way of the Young Offenders Act or Youth
Criminal Justice Act.

13. Provide detailed answers for each question. Wherever possible, provide circumstances, locations,
dates (including month and year), why and how the event/incident took place, as applicable.

14. You may contact the Recruitment Officer to ask questions or for clarifications before returning your
Questionnaire.

15. Review your answers, sign and date the Final Declaration, Acknowledgment and Consent on the
last page.



CANADA BORDER SERVICES AGENCY PROTECTED B
(once completed)
Applicant Name: _____________________
(Print)
- 7 7
SECTION A - Driving History

1. Have you ever applied for a driver's licence and been denied or has your driver's licence ever
been restricted, suspended or revoked for any reason?
Yes No

If yes, explain:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

2. Have you ever been refused automobile insurance or had it cancelled or suspended?
Yes No

If yes, explain:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

3. Do you have any outstanding motor vehicle/driving violation(s) and/or unpaid traffic tickets,
including parking tickets? Yes No

If yes, explain
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________


SECTION B Alcohol/Drugs

4. How much alcohol do you consume per week on average?

Type of Alcohol Amount and Frequency
(weekly basis)
Circumstances of Use





5. Have you ever purchased alcohol with a counterfeit ID, purchased alcohol for minors or given
alcohol to minors? Yes No

If yes, explain:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

6. Have you ever operated a motorized vehicle or vessel while under the influence of alcohol
and/or illegal drugs? Yes No

CANADA BORDER SERVICES AGENCY PROTECTED B
(once completed)
Applicant Name: _____________________
(Print)
- 8 8
If yes, explain:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

7. Have you ever been treated or sought treatment or counselling for a substance (drugs,
alcohol) abuse problem? Yes No

If yes, explain:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________


8. Have you ever used any illegal/illicit drugs that were not prescribed by a physician?
Yes No

If yes, provide the requested information for each drug and explain the circumstances of use
in the chart below:

Drug Method and
Frequency of
Use
Approximate
dates of use (first
time, last time)
Circumstances/
Motives for use
Means to
obtain
drugs
Financial
outlay (How
much do/did
you spend on
drugs on a
monthly
basis?)
Acid/LSD


Catha Edulis (Khat)


Cocaine


Crack


Crystal Meth


Date Rape (DMX,
GHB, Rohyphonol)

Ecstasy


Hash/Hash Oil


Heroin


Inhalants (glue,
gasoline, paint)

Ketamine


Marijuana


Mescaline


Methamphetamine
CANADA BORDER SERVICES AGENCY PROTECTED B
(once completed)
Applicant Name: _____________________
(Print)
- 9 9

Mushrooms


PCP


Steroids


Other (specify)



9. Have you or your spouse/common law partner or cohabiter ever sold any illegal or
prescription/non-prescription drugs?
Yes No

If yes, explain:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

10. Have you or your spouse/common law partner or cohabiter ever grown, produced or
harvested illegal drugs and/or, imported, exported or mailed any illegal or prescription drugs?
Yes No

If yes, explain:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

11. Have you ever misused or been dependent upon prescription or non-prescription drugs?
Yes No

If yes, provide information for each drug and explain the circumstances of use in the chart
below:

Drug Method and
Frequency of Use
Approximate dates
of use (first time,
last time)
Circumstances/
Motives for use
Financial outlay
(How much
do/did you spend
on drugs on a
monthly basis?)
Antihistamines


Dilaudid


Methadone


Oxycodine


Oxycontine


Percocet


Percoden


CANADA BORDER SERVICES AGENCY PROTECTED B
(once completed)
Applicant Name: _____________________
(Print)
- 10 10
Prozac


Ritalin


Valium


Zanax


Other
(specify):



































































12. Have you ever been charged, convicted of an offence for which a pardon was not received or
granted a discharge for any offence involving trafficking, importing and/or exporting drugs or
controlled substances?
Yes No

If yes, explain:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

13. Do you knowingly associate with anyone who uses illegal drugs (family, friends, etc)?
Yes No

If yes, explain:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________


SECTION C - Gambling

NOTE: Provide any requested currency amounts in Canadian dollars.

14. Do you or your spouse/common law partner or cohabiter gamble (including lottery, casinos,
online gaming, scratch tickets, etc)?
Yes No

If yes, how often and explain:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

CANADA BORDER SERVICES AGENCY PROTECTED B
(once completed)
Applicant Name: _____________________
(Print)
- 11 11
15. How much money have you or your spouse/common law partner or cohabiter spent,
wagered, lost or won in the last year as a result of gambling to the best of your lnowledge?
Please record in the chart below:


Amount
Spent
$
Wagered
$
Lost
$
Won
$
Owe
$

16. Do you or your spouse/common law partner or cohabiter presently owe any gambling debts?
Yes No

If yes, specify who owes the debts.
__________________________________________________________________________

Please record how much you or your spouse/common law partner or cohabiter owe in the
chart below:


Amount
Spent
$
Wagered
$
Lost
$
Won
$
Owe
$

* Remember to provide amounts in Canadian dollars.


SECTION D - Security

17. Have you ever provided fraudulent or misleading information regarding yourself or other
people or persons seeking entry into Canada?
Yes No

If yes, explain:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

18. Have you ever possessed or do you currently possess false/fraudulent identification?
Yes No

If yes, explain:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

19. Do you possess multiple citizenships or were you ever a citizen of another country other than
Canada? If yes, identify type of citizenship and country below:

Multiple Former Country _____________________________

20. Do you or your spouse/common law partner or cohabiter hold or have previously held any
loyalties to organizations, or persons, or beliefs, which could supersede or take precedence
over your loyalty to Canada?
Yes No

If yes, explain (name and type of organization, etc.):
CANADA BORDER SERVICES AGENCY PROTECTED B
(once completed)
Applicant Name: _____________________
(Print)
- 12 12
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

21. Do you have any foreign property, business connections, or financial interests?
Yes No

If yes, explain:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

22. Are you susceptible to or have you ever been subjected to blackmail/attempted blackmail or
coercion?
Yes No

If yes, explain:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________


SECTION E - Use of Force

23. Have you ever committed an act of domestic abuse including the use of, or the threat of use
of violence against your spouse, partner, parents, children, siblings, pets, etc.?
Yes No

If yes, explain:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

24. Have you ever been charged, convicted of an offence for which a pardon was not received or
granted a discharge for any offence involving the misuse, possession or storage of a firearm
or other weapon?
Yes No

If yes, explain:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

25. Have you ever pointed a weapon such as a knife or a firearm whether loaded or not at
yourself or another person?
Yes No

If yes, explain:
__________________________________________________________________________
CANADA BORDER SERVICES AGENCY PROTECTED B
(once completed)
Applicant Name: _____________________
(Print)
- 13 13
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

26. Have you ever been accused, investigated, charged or convicted of an offence for which a
pardon was not received related to the excessive use of force?
Yes No

If yes, explain:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

27. Have you ever been refused a firearms permit or had a permit revoked?
Yes No

If yes, explain:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________


SECTION F - Unlawful Sexual Activity

28. Have you ever travelled outside of Canada for the purpose of engaging in sexual activity with
a person under the age of 18 (sexual tourism)?
Yes No

If yes, explain:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

29. Have you ever solicited the services of a prostitute?
Yes No

If yes, explain:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

30. Have you ever engaged in sexual activities with someone who was under age 16 or have you
ever had sex with someone against his/her will or without his/her consent (includes persons
unable to give permission due to a medical condition, mental health issue, alcohol, drugs, or
other reasons)? Yes No

If yes, explain:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
CANADA BORDER SERVICES AGENCY PROTECTED B
(once completed)
Applicant Name: _____________________
(Print)
- 14 14

31. Have you ever viewed, possessed, stored, produced or downloaded images of child
pornography, bestiality and/or other prohibited subject matter on the Internet?
Yes No

If yes, explain:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________


SECTION G - Involvement with Law Enforcement

32. Have you ever had a court order issued against you (includes search warrant, arrest warrant,
peace bond, restraining order(s), protection order or restitution order)?
Yes No

If yes, explain:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

33. Have you ever done anything for which you could have been arrested but were not?
Yes No

If yes, explain:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

34. Have you ever been wanted, investigated, arrested, charged and/or convicted of any criminal
offence for which a pardon was not received in Canada or in a foreign country?
Yes No

If yes, explain:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

35. Have you or your spouse/common law partner or cohabiter ever associated in any way with
organized crime or with a terrorist group?
Yes No

If yes, explain:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

CANADA BORDER SERVICES AGENCY PROTECTED B
(once completed)
Applicant Name: _____________________
(Print)
- 15 15
36. Have you ever been questioned or investigated by the CBSA (Immigration, Customs, Canada
Food Inspection Agency), any police agency or any Government Department/Agency as a
complainant, a witness or a suspect?
Yes No

If yes, explain:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

37. Have you ever stolen anything (includes shoplifting)?
Yes No

If yes, explain:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

38. Have you ever falsified an insurance claim (e.g. motor vehicle injury claim, worker's
compensation claim, theft claim, property loss or damage, etc.)?
Yes No

If yes, explain:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

39. Have you or your spouse/common law partner or cohabiter ever illegally imported or exported
goods of any kind from or into any country including Canada?
Yes No

If yes, explain:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

40. Have you or your spouse/common law partner or cohabiter ever been put on probation or
court supervision?
Yes No

If yes, explain:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________


SECTION H - Computers and Technology

41. Have you ever used a phone, a computer or the Internet for illegal or nuisance purposes (i.e.
Child Pornography, Hacking, Spamming, Harassment)?
CANADA BORDER SERVICES AGENCY PROTECTED B
(once completed)
Applicant Name: _____________________
(Print)
- 16 16
Yes No

If yes, explain:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

42. Have you ever hacked and/or attempted to gain unauthorized access into any computer
system (i.e. business, private, law enforcement, Canadian or foreign government systems)?
Yes No

If yes, explain:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

43. Have you or your spouse/common law partner or cohabiter ever committed credit card/bank
card fraud, identity theft, or any other form of false pretense over the Internet?
Yes No

If yes, explain:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________


SECTION I - Employment

44. Did you intentionally omit any prior places of employment from your employment application
(within the past ten years or from the age of 16)? Yes No

If yes, explain:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

45. Have you ever been an employee of and/or have you ever been refused employment with the
Government of Canada, the military, a police service, and/or an intelligence service (includes
the CBSA, the Department of National Defence, the RCMP and the Canadian Security
Intelligence Service)? Yes No

If yes, explain:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

46. Have you ever been employed and deliberately not disclosed your income for tax purposes?
Yes No

CANADA BORDER SERVICES AGENCY PROTECTED B
(once completed)
Applicant Name: _____________________
(Print)
- 17 17
If yes, explain:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

47. Have you ever received any type of oral or written reprimand or any other type of discipline
(suspension, time off without pay, etc.)?
Yes No

If yes, explain:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

48. Have you ever had your employment terminated with or without cause?
Yes No

If yes, explain:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

49. Have you ever received a verbal or written warning regarding absenteeism?
Yes No

If yes, explain:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________


SECTION J - Lifestyle

50. Have there been any major changes in your lifestyle during the past five (5) years, such as
divorce and/or separation, a lottery win, a financial loss, bankruptcy, an illness, a death, job
loss, etc.? Yes No

If yes, explain:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________


SECTION K Affiliations

51. Have you, your spouse/common law partner or cohabiter or any of your family members ever
been employed by a government or an organization (Canadian or foreign) in a security-
related capacity?
Yes No
CANADA BORDER SERVICES AGENCY PROTECTED B
(once completed)
Applicant Name: _____________________
(Print)
- 18 18

If yes, explain and provide details on the group/organization:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________


52. Have you, your spouse/common law partner or cohabiter or any of your family members ever
held a position of authority in any government, or judiciary or a political party outside of
Canada?
Yes No

If yes, explain and provide details on the group/organization and your relationship with that
family member:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________


53. Have you, your spouse/common law partner or cohabiter or any of your family members ever
been in a military, militia or civil defence unit or the police?
Yes No

If yes, explain and provide details on the group/organization and your relationship with that
family member:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

54. Have you, your spouse/common law partner or cohabiter or any of your family members ever
been a member or associated with any group or organization which has engaged in or
advocated violence, hate propaganda, or which has been associated with criminal activity at
any time?
Yes No

If yes, explain and provide details on the group/organization:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

55. Have you or your spouse/common law partner or cohabiter ever sponsored anyone from
another country to come to Canada?
Yes No

If yes:

a) Who have you sponsored? Please provide details regarding the principal applicant that
you are currently or have sponsored in the past, including their country of origin as well as the
country they are being or were sponsored from, the date of sponsorship, their full name(s)
and date(s) of birth as well as the current address.
CANADA BORDER SERVICES AGENCY PROTECTED B
(once completed)
Applicant Name: _____________________
(Print)
- 19 19
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

b) What form of sponsorship did you use (ie. family, spouse or common-law, employment,
etc.)?
_________________________________________________________________________
_________________________________________________________________________

c) Indicate the nature of your relationship to the principal applicant?
_________________________________________________________________________
_________________________________________________________________________

d) ndicate the principal applicant's current status in Canada?
_________________________________________________________________________
_________________________________________________________________________

e) Indicate if you are aware of the principal applicant's activities and the relevant details of
those activities, including any criminal activity, any associations with any group or
organizations which have engaged in or advocated violence, or which have been associated
with criminal activity at any time along with the name and type of activity / organization.
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

(If more space is required, please provide the requested information in the same format on
another sheet)


SECTION L Immediate Relatives/Spousal/Partner Information

56. Please provide the requested information on current and previous spouses/common-law
partner/partners:

Marital Status/Common-Law Partner/Partner

1
Current Relationship Status:

Full Name of Current Spouse/Common Law Partner/Partner:

Maiden Name (if applicable):

Present Citizenship of current Spouse/Common Law Partner/Partner:

Date of marriage/common-law partnership:

City, province or state, and country of marriage/common-law partnership:

City, province or state, and country of birth:

Date of birth:

Present address:
CANADA BORDER SERVICES AGENCY PROTECTED B
(once completed)
Applicant Name: _____________________
(Print)
- 20 20

Name and address of employer (job title):

If separated, widowed or divorced, specify date:


2
Full Name of Previous Spouse/Common Law Partner/Partner:

Maiden Name (if applicable):

Present Citizenship of former Spouse/Common Law Partner/Partner:

City, province or state, and country of birth (if known):

Date of birth:

Date of marriage/common-law partnership:

Date of divorce/separation/deceased:

City, province or state, and country of marriage/common-law parter:

City, province or state, and country of divorce:



57. Please provide the requested information on relatives including: mother, father, brothers,
sister, all children 18 years and over, include half or step relatives, your current spouse's or
common law partners father and mother including half or step relatives and any cohabiter(s):

Relatives (including those living outside Canada) and Cohabiter(s)

1
Full name (surname and all given names, including maiden name:

Relationship:

City, province or state, and country of birth:

Date of birth:

Present address:

Name and address of employer (job title):

Date of death (if applicable):


2
Full name (surname and all given names, including maiden name:

Relationship:

City, province or state, and country of birth:

Date of birth:

Present address:

Name and address of employer (job title):

CANADA BORDER SERVICES AGENCY PROTECTED B
(once completed)
Applicant Name: _____________________
(Print)
- 21 21
Date of death (if applicable):


3
Full name (surname and all given names, including maiden name:

Relationship:

City, province or state, and country of birth:

Date of birth:

Present address:

Name and address of employer (job title):

Date of death (if applicable):


4
Full name (surname and all given names, including maiden name:

Relationship:

City, province or state, and country of birth:

Date of birth:

Present address:

Name and address of employer (job title):

Date of death (if applicable):


5
Full name (surname and all given names, including maiden name:

Relationship:

City, province or state, and country of birth:

Date of birth:

Present address:

Name and address of employer (job title):

Date of death (if applicable):


6
Full name (surname and all given names, including maiden name:

Relationship:

City, province or state, and country of birth:

Date of birth:

Present address:

Name and address of employer (job title):
CANADA BORDER SERVICES AGENCY PROTECTED B
(once completed)
Applicant Name: _____________________
(Print)
- 22 22

Date of death (if applicable):


7
Full name (surname and all given names, including maiden name:

Relationship:

City, province or state, and country of birth:

Date of birth:

Present address:

Name and address of employer (job title):

Date of death (if applicable):


(If more space is required, please provide the requested information in the same format
on another sheet)
CANADA BORDER SERVICES AGENCY PROTECTED B
(once completed)
Applicant Name: _____________________
(Print)
- 23 23

This Integrity Questionnaire is not complete until you have read, understood, signed, and
dated the Final Declaration, Acknowledgment, and Consent. If sent to the CBSA
Recruitment Office without your printed name, signature, and date on this page, this
Integrity Questionnaire will be returned to you, if you provide a forwarding address. If no
forwarding address is provided, your application will be destroyed.
Note: This will delay your application process.


Final Declaration, Acknowledgment, and Consent of: _________________________
Name of Applicant (print)


I, the undersigned, hereby declare that the information I have provided in this Integrity
Questionnaire (referred to on this page as the preceding information) is up to date,
accurate, complete, and honest, to the best of my knowledge and belief.

I acknowledge that the preceding information may be used in accordance with the
notices on Page 2, 3, 4 and 5 of this Integrity Questionnaire and I consent to its
subsequent verification and/or use for the purposes of evaluating my suitability and
reliability, and the security screening assessment.

I further acknowledge that the verification and/or use of the preceding information may
also occur when my reliability status, security clearance or site access - if issued - are
updated or otherwise reviewed for cause under the Policy on Government Security.

I acknowledge that, if I have indicated in this Integrity Questionnaire that I have
committed a criminal offence or that I pose a risk to the safety of others, I am to provide
this information to the CBSA.

If I return this completed Integrity Questionnaire containing criminal admissions, I
acknowledge that the CBSA may use and/or disclose such information for a law
enforcement or public safety purpose as described under the "Notice Regarding
Misconduct, Criminal Offences and Risk to the Safety of Others" on Page 4 of this
Integrity Questionnaire.

By my signature below, I declare that I have read and understand how the preceding
information will be managed and I hereby consent to the use and disclosure of my
personal information as described herein the Integrity Questionnaire.





____________________________________ _____________________
Signature of Applicant Date