Security Clearance Fingerprint Third Party Consent to ReleasePersonal Information

Access to Cannabis for Medical Purposes Regulations (ACMPR)

For the purpose of your security clearance application, a Canadian police force, the Royal Canadian Mounted Police (RCMP), or private fingerprinting agencies accredited by the RCMP can submit, on your behalf, your fingerprints electronically to the RCMP for the purpose of a criminal record check. The fees for taking electronic fingerprints vary and must be paid by the applicant at the time the service is performed. I,

(Print full name of the person applying for the security clearance)

born require criminal record verification in order to obtain (Day) (Month) (Year)

a (Specify job title and name of licensed producer [corporation or individual] under the ACMPR)

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

Health Canada AL: 0300A Ottawa, Ontario K1A 0K9

I understand that I have the right to receive the results directly from the RCMP and that the assistance of a third party is not necessary to obtain these results. I have read and signed the 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.

DCN:

Right Thumb Left Thumb Right Index Left Index Right Middle Left Middle Right Ring Left Ring Right Small Left Small

Applicant Signature: ______________________________

Dated this day of , .

Third Party Consent to Release Personal Information - Pub: 130074 3

Important information and instructions for completion of Security Clearance Fingerprint Third Party Consent to Release Personal Information form under the

Access to Cannabis for Medical Purposes Regulations (MMPR)

Note: As part of the Application to become a Licensed Producer under the Access to Medical Cannabis for Medical Purposes Regulations and in the case of changes of personnel, a Security Clearance Application Form, including the security clearance applicant’s fingerprints must be submitted for individual applicants, proposed senior person in charge, proposed responsible persons in charge, and proposed alternate persons in charge. In the case of a corporate applicant, each director and officer of the corporation must apply for a security clearance and also submit fingerprints as part of their security clearance application. All security clearance applicants must complete a Security Clearance Fingerprint Third Party Consent to Release Personal Information form, in accordance with the instructions below.

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, whetherelectronically or by mail (in case of roll and ink prints).

6. This form must be submitted as part of your Security Clearance Application Form package.

*Form C-216C is the standard RCMP form used for fingerprinting• This form is not available online• You must have your fingerprints taken on Form C-216C at your local police station or private fingerprinting

agency accredited by the RCMP. Please see this link for a list of accredited private fingerprinting agencies• Depending on the police jurisdiction, a fee may be required