Step 1 (D) - Security Clearance Form

YOU HAVE BEEN IDENTIFIED AS “KEY PERSONNEL” ASSOCIATED WITH A CANNABIS LICENSE APPLICATION.  PLEASE FILL OUT THE FOLLOWING COMPLETELY AND TRUTHFULLY TO THE BEST OF YOUR KNOWLEDGE.

This is form 4 of 4 of required information to complete the application.

This is required for EVERY Individual Identified as Key Personnel in Step 1(B)

Preferred Official Language *
Choose ONLY one
Legal Name *
Legal Name
of above individual
Date of Birth *
Date of Birth
If born outside Canada, select 'OTHER' and fill in country information below
Write the State/Province and Country of your birth
As given on your current valid Provincial or Federal ID
As given on your current valid Provincial or Federal ID
Weight given in lbs. or kg. *
Choose one
As given on your current valid Provincial or Federal ID
Height given in ft or cm *
Photo ID *
Must be valid Provincial or Federal ID We will follow up with you where you can upload or send an image of the identification
Residential Address *
Residential Address
Current Address, if you have lived here less than 5 years, you will need to list all other addresses you have lived at for the past 5 years below.
Other than your current Address, list ALL addresses Date Starting-Ending, ADDRESS 1, Date Starting-Ending, ADDRESS 2, etc.
Date Starting-Ending, Company Name, Title OR Date Starting-Ending, Unemployed
For Each Job OR period of Unemployment Date Starting-Ending, Company Name, Title OR Write Date Starting-Ending, Unemployed
Choose ONE
List any Education or certificate program attended in the last 5 years Date Starting-Ending, School, Degree/Certificate Earned or In-progress
Choose One
List any Marriage (or Common-law) for the last 5 years Date Starting-Ending, Spouse Name If you are currently single and have been for the past 5 years write NA
Have you lived or traveled outside Canada for more than 90 days in the past 5 years? *
Choose One
If you answered YES to the above, provide the following information for each trip 90 days or longer: DATE (Starting Ending), LOCATION, REASON FOR TRAVEL
Signed Forms
You will be sent the following forms and will need to return the ORIGINALS of each, if you have already filled out the forms, please mark the box below
Write your name below
Today's Date *
Today's Date