Questionnaire on Time Spent Outside of Canada

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In order to conduct Out-of-Country Verifications, the Industrial Personnel Security Services Directorate
has worked with our internal and external security partners to develop tools that will help us mitigate
security concerns. As your security screening request contains an Out-of-Country component, you are
required to complete the Questionnaire on Time Spent Outside of Canada.

We rely on obtaining timely, accurate and complete information from our security partners in order to
fully assess the application for the level of security requested. If the information provided to us is
incomplete or cannot provide reasonable assurance with respect to your time spent outside of Canada,
your request may be denied.

Important information for the Applicant

 The Questionnaire on Time Spent Outside of Canada is available in both official languages (English
and French). You may complete the Questionnaire in the language of your choice.
 You should answer all questions contained in the Questionnaire on Time Spent Outside of Canada
accurately, completely, thoroughly and honestly to the best of your knowledge and belief. Please be
aware that a completed Questionnaire on Time Spent Outside of Canada does not automatically
result in the approval of a security screening request.
 Your Reliability Status / Security Clearance request may be denied if the information you provide in
this questionnaire cannot be validated.
 We are collecting the personal information you provide on the Questionnaire on Time Spent Outside
of Canada to assist in determining your eligibility to obtain and maintain a security screening status
or clearance. The information requested is essential for making these determinations and, should it
not be provided, may result in your disqualification and/or our inability to proceed with the security
screening process.

Please Note: The information provided will be assessed in accordance with the requirements laid out
in the Treasury Board Standard on Security Screening. Your Reliability Status / Security Clearance
request may be denied if the information cannot be validated.

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Declaration, Acknowledgement, and Consent

Name of applicant
SANDEEP PATNALA
_____________________________________________________________________________________

Current address (Suite, Street Number, Street Name, City, Province/Territory, Postal Code, Country)
31 GATEWAY DR, GUELPH, ON, N1H6X1, CANADA
_____________________________________________________________________________________

Please select your language of preference:

English French

Declarations, Acknowledgements, and Consent Applicant Initials

I have read and understand the contents of this Questionnaire on Time Spent
Outside of Canada, including the notices and instructions set out in the previous SP 
page.
I declare that the information I have provided in this Questionnaire on Time Spent
SP 
Outside of Canada is up-to-date, accurate, and complete.
I understand that the consequences of not being completely honest and forthright  
in this Questionnaire on Time Spent Outside of Canada could hinder my eligibility to SP 
obtain and maintain a reliability status, security clearance or site access.  
I understand that the information provided in this Questionnaire on Time Spent
Outside of Canada may affect my opportunities for employment with, or at, the  SP
Government of Canada.
I consent to my personal information being used for security screening
SP 
purposes pursuant to the Treasury Board's Policy on Government Security.
I understand the information and documentation provided throughout this
Questionnaire will be assessed in accordance with the requirements set out in the
Treasury Board Standard on Security Screening and that my security screening SP
request may be denied if the information cannot be validated.

Signature of applicant: SANDEEP PATNALA Date:2020 SEPTEMBER 12

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Please complete each of the fourteen (14) questions contained in this Questionnaire on Time Spent
Outside of Canada and provide a copy of the supporting documents as requested.

1. Please provide your legal name as per the format below:

SURNAME, GIVEN NAME(S) (MAIDEN NAME)

__SANDEEP PATNALA__________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Note: If you have legally changed your name (for reasons other than marriage), please provide your
previous name(s) and include supporting documentation in your e-mail submission.

1. What is your current status in Canada? Please select all that apply:

Canadian Citizen
Permanent Resident
Refugee Claimant
Study Permit
Visitor Record
Work Permit

If other, please state here: __________________________________________.

Note: Provide a copy of your status documents (Canadian citizenship certificate, card or passport,
permanent residence card, valid refugee claimant document, valid study permit, valid visitor record,
valid work permit) in your e-mail submission.

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3. Do you hold any citizenship other than Canadian?

Yes No

___INDIAN____________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________

Note: Please provide proof of citizenship in your e-mail submission (Certificate of Citizenship,
Passport, National Identification Card) for each of the citizenships declared above.

4. Do you have any valid passports currently in your possession?

Yes No

If yes, complete the table below (If necessary, add pages to the end of the Questionnaire using a similar format).

Validity Period
Issuing Country Passport Number
from YYYY/MM to YYYY/MM

INDIA S4709828 2018/02 TO 2028/02

Note: Please attach a copy of each passport in your e-mail submission.

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5. Do you have relationships with persons living outside of Canada? (Persons refers to family
members, partners, friends, colleagues, etc.)
*Friend refers to persons with whom the applicant has associated within the last 10 years for a Security Clearance
or 5 years for a Reliability Status, Site Access Status or Site Access Clearance.
**Only include persons you continue to have regular contact with; for example - contact by phone, email, chatting,
social networking, etc.

Yes No

If yes, complete the table below (If necessary, add pages to the end of the Questionnaire using a similar format).
Occupation
(If retired, please
Given Names Surname Relationship City and Country
state occupation prior
to retirement).
GANESH BABU PATNALA FATHER CHIEF ENGINEER, HYDERABAD,
INDIAN RAILWAYS INDIA
PATNALA MOTHER HOUSE WIFE HYDERABAD,
VIJAYA INDIA
PATNALA SISTER PROJECT MANAGER, HYDERABAD,INDIA
NYMISHA HYUNDAI

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6. Do you have any financial, personal or property assets outside of Canada?

Yes No

If yes, complete the table below (If necessary, add pages to the end of the Questionnaire using a similar format).
Description of Asset(s) Location of Asset (City and Country)
VIJAYAWADA, INDIA
SAVINGS BANK ACCOUNT

Note: Financial, personal or property assets includes bank accounts held in countries other than
Canada.

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7. Have you ever studied at a post-secondary institution outside of Canada?

Yes No

If yes, complete the table below: (If necessary, add pages to the end of the Questionnaire using a similar format).

Years Attended
Institution Name Credential Received
(from YYYY to YYYY)
JAWAHARLAL NEHRU BACHELORS OF ENGINEERING 2005-2009
TECHNOLOGICAL UNIVERSITY
BIRLA INSTITUTE OF MASTERS OF ENGINEERING 2009-2011
TECHNOLOGY

Note: Please provide proof of studies abroad by providing any of the following documents for each
education credential declared in your e-mail submission:

1. Certificate
2. Diploma
3. Transcripts

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8. Have you traveled outside of Canada within the reporting period?

*If applying for a Reliability Status, Site Access Status or Site Access Clearance, please provide information from the
past five (5) calendar years.
**If applying for a Security Clearance, please provide information from the past ten (10) calendar years.

Yes No

If yes, complete the table below (If necessary, add pages to the end of the Questionnaire using a similar format).

Period from
Duration
Country Visited YYYY/MM Purpose of Travel
(Number of Weeks)
to YYYY/MM

INDIA 2019/11 TO 4 TO ATTEND SISTER WEDDING

2019/12

THAILAND 2016/01 TO 2 VACATION

2016/01

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Note: If duration of travel is less than one (1) week, please specify the travel duration in number of
days to the best of your ability.

9. Have you worked outside of Canada or do you currently maintain an employment outside
of Canada?
*If applying for a Reliability Status, Site Access Status or Site Access Clearance, please provide information from the
past five (5) calendar years.
**If applying for a Security Clearance, please provide information from the past ten (10) calendar years.

Yes No

If yes, complete the table below (If necessary, add pages to the end of the Questionnaire using a similar format).
Period from YYYY/MM
Company Name City and Country Position Title
To YYYY/MM
VIJAYAWADA, INDIA ASSISTANT 2014/06 TO 2016/12
LAKIREDDY BALIREDDY PROFESSOR
COLLEGE OF
ENGINEERING

Note: Please provide proof of employment abroad in your e-mail submission (Work Contract, Letter of
Reference, Relieving Letter), as well as the name, valid telephone number and valid e-mail address of
a contact person for the companies indicated above (this person should preferably speak English or
French).

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Questionnaire on Time Spent Outside of Canada
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10. Have you previously applied for a security status and/or clearance with:

 a Government of Canada institution

 a foreign government and/or private sector organization
 an international body (such as NATO)

Yes No

If yes, complete the table below (If necessary, add pages to the end of the Questionnaire using a similar format).
Institution, foreign country, or Security Clearance level and Application Date (YYYY/MM)
international body Employment Position

NA NA NA

11. Have you had any professional or social contacts with representatives of foreign
governments? If so, which government(s) and under what circumstances?

Yes No

If yes, complete the table below (If necessary, add pages to the end of the Questionnaire using a similar format).
City and Country Contact Date
Government Circumstance
Ville et Pays (YYYY/MM)
NA NA NA NA

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12. Do you currently financially support any person(s) or organization(s) outside of Canada?

Yes No

If yes, complete the table below (If necessary, add pages to the end of the Questionnaire using a similar format).
Approximate amount
Name of Person / Association / contributed within one (1)
City and Country
Club / Organization / Group calendar year in Canadian
dollars (CAD).
NA NA NA

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13. Please state your current employment position(s) and company name(s):

(If necessary, add pages to the end of the Questionnaire using a similar format).
Name of Position(s) Company Name City and Country
Colt Canada Kitchener, ON, Canada
Quality Inspector -ii

Note: Please provide proof of employment in your e-mail submission (Work Contract, Letter of
Reference) for each of the positions declared above.

14. Please read both of the statements below then sign and date the Questionnaire on Time
Spent Outside of Canada:

Consent Statement
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 I no longer
require a reliability status, a security clearance or a site access clearance, my employment or contract is terminated, or until I otherwise revoke
my consent, in writing to the authorized security official.

Privacy Act Statement

The information on this form is required for the purpose of providing a security screening assessment. It is collected under the authority of
subsection 7(1) of the Financial Administration Act and the Policy on Government Security (PGS) of the Government of Canada, and is protected
by the provisions of the Privacy Act in institutions that are covered by the Privacy Act. Depending on the level of security screening required,
the information collected by the government institution may be disclosed to the Royal Canadian Mounted Police (RCMP) and the Canadian
Security Intelligence Service (CSIS), which conduct the requisite checks and/or investigation in accordance with the PGS and to entities outside
the federal government (e.g. credit bureaus). It is used to support decisions on individuals working or applying to work through appointment,
assignment or contract, transfers or promotions. It may also be used in the context of updating, or reviewing for cause, the reliability status,
security clearance or site access, all of which may lead to a re-assessment of the applicable type of security screening. Information collected by
the government institution, and information gathered from the requisite checks and/or investigation, may be used to support decisions, which
may lead to discipline and/or termination of employment or contractual agreements.

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Questionnaire on Time Spent Outside of Canada
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Signature Date (YYYY/MM/DD)
SANDEEP PATNALA 2020/09/12

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