Csc Scc 1279 Form PDF Details

The Csc Scc 1279 form, employed by the Correctional Service Canada, is a crucial document designed for individuals seeking institutional access, necessitating a CPIC clearance request—a measure to ensure safety and security within correctional facilities. Its components are meticulously structured, beginning with a section for the applicant to fill out personal information clearly, ensuring accuracy and traceability. Additionally, it includes sections on physical description, address details, and a series of security-related questions aimed at assessing the applicant’s criminal record, any known associations with incarcerated individuals, and the perceived risk such associations might pose. Moreover, it demands an unequivocal consent from the applicant, permitting the Correctional Service of Canada to undertake any necessary police inquiries to verify the applicant's suitability. This consent also acknowledges the limited liability of the Correctional Service of Canada for any harm that might befall the applicant during their visit, barring negligence from the Service's employees. False information provision is strictly warned against, as it could lead to access denial, highlighting the form’s role in maintaining a secure environment. The form concludes with a section for office use only, including the decision on clearance, thereby encapsulating the thorough vetting process applicants undergo to gain access to correctional institutions.

QuestionAnswer
Form NameCsc Scc 1279 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namescorrectional services institutional access cpic clearance request, scc 1279, asking for a clearance certificate form tx19, corrections canada cpic clearance forms

Form Preview Example

Correctional Service

Service correctionnel

Canada

Canada

ACCÈS À UN ÉTABLISSEMENT

INSTITUTIONAL ACCESS

DEMANDE DE VÉRIFICATION

CPIC CLEARANCE REQUEST

DU DOSSIER AU CIPC

PLEASE PRINT INFORMATION CLEARLY - VEUILLEZ ÉCRIRE EN LETTRES MOULÉES

PROTECTED

B

ONCE COMPLETED

PROTÉGÉ

UNE FOIS REMPLI

PUT AWAY ON FILE – CLASSER AU DOSSIER ADMINISTRATIVE OR OPERATIONAL FILE DOSSIER ADMINISTRATIF OU OPÉRATIONNEL

Original = 3170-12

Institution – Établissement

EIFW

Request received

Date (YYAA-MM-DJ)

 

Demande reçue le

 

 

 

PUT AWAY ON FILE

► 3170-12

CLASSER AU DOSSIER

A. PERSONAL INFORMATION – RENSEIGNEMENTS PERSONNELS

Surname

Full name (no nicknames or initials)

Maiden name (if applicable)

Nom de famille

Nom au complet (pas de surnoms ou d’initiales)

Nom de jeune fille (s'il y a lieu)

Date of birth

Date de naissance (YYAA-MM-DJ)

Place of birth – Lieu de naissance

 

 

City/Town – Ville ou municipalité

Province/State – Province ou état

Country – Pays

B. PHYSICAL DESCRIPTION – DESCRIPTION PHYSIQUE

Male Homme

 

Height – Grandeur

Weight – Poids

Eye color – Couleur des yeux

Hair color

Female

Couleur des cheveux

 

 

 

Femme

C. ADDRESS – ADRESSE

Street – Rue

City/Town – Ville ou municipalité

Province

Postal Code - Code postal

Telephone number – Numéro de téléphone

Home – Domicile

Work – Bureau

 

 

Representing (name of company/organization) – Représente (nom de la compagnie ou de l’organisation)

D. GENERAL INFORMATION – RENSEIGNEMENTS GÉNÉRAUX

 

Have you ever been convicted of a criminal offence for which you have not been granted a pardon, or an offence for which you have been granted a pardon

Yes

 

No

1.

and such a pardon has been revoked?

 

 

 

 

 

 

 

 

 

 

 

 

Avez-vous déjà été reconnu coupable d'une infraction criminelle pour laquelle on ne vous a pas octroyé un pardon ou d'une infraction pour laquelle on vous a

 

Oui

 

Non

 

octroyé un pardon qui a été révoqué?

 

 

 

 

 

 

 

 

2.

Do you personally know of any person incarcerated in a correctional facility?:

If so, provide names - Si oui, fournir son nom :

 

Yes

 

No

Connaissez-vous personnellement une personne qui est incarcérée dans un établissement correctionnel?

 

 

 

 

 

 

 

 

 

 

 

Oui

 

Non

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

3.

Do you have any reason to believe coming into contact with this person could pose a risk to your or their personal safety?

 

 

 

 

Avez-vous des raisons de croire que le fait d'entrer en contact avec cette personne pourrait présenter un risque pour votre sécurité personnelle ou la sienne ?

 

Oui

 

Non

 

 

 

4.

Are you related/associated to an inmate or on an inmate's visiting list?

 

 

 

 

 

Yes

 

No

 

 

 

 

 

 

Êtes-vous apparenté ou associé à un détenu ou inscrit sur la liste des visiteurs d’un détenu?

 

 

 

 

 

Oui

 

Non

 

 

 

 

 

 

 

If you have answered YES to any of the above, please explain below. – Si vous avez répondu OUI à une des questions ci-dessus, veuillez fournir une explication ci-après.

►

E. SIGNATURE (When sections A to E are filled out completely, please return the completed form to the institution for approval.)

(Une fois que les sections A à E ont été remplies, veuillez retourner le formulaire dûment rempli à l'établissement aux fins d’approbation.)

In making this application, I hereby give the Correctional Service of Canada my consent to use the information provided on this form to conduct such inquiries with police authorities as may be necessary to ascertain my suitability. Finally, I acknowledge that the Correctional Service of Canada has no responsibility for any harm that may come to me in the course of my activities, except where such harm is a direct result of negligence on the part of an employee(s) of the Service.

NOTE: Access may be denied for submitting false information. Passes may be issued for those receiving clearance and approval.

En soumettant la présente demande, j’autorise le Service correctionnel du Canada à se servir des renseignements fournis dans le formulaire afin de mener, auprès des services de police, toute enquête jugée nécessaire pour vérifier mon admissibilité. Par ailleurs, je conviens que le Service correctionnel du Canada ne peut être tenu responsable d’un préjudice subi dans le cadre de mes activités sauf si ce préjudice est directement attribuable à la négligence d’un ou de plusieurs employés du Service.

NOTA : Tout demandeur qui fournit de faux renseignements peut se voir refuser l’accès à l’établissement. Un laissez-passez peut être émis aux demandeurs dont la demande d’accès est approuvée.

Applicant’s signature – Signature du demandeur

 

 

 

 

Date (YYAA-MM-DJ)

►

 

 

 

 

 

 

F. FOR OFFICE USE ONLY – RÉSERVÉ AU SCC

 

 

 

 

 

Reason for clearance – Motif justifiant la demande d’accès

 

 

 

 

 

Institutional tour for Forum of Canadian Ombudsman

 

 

 

 

 

 

 

 

 

Department making the request (please print)

 

Signature of Division Head

 

 

Unité qui soumet la demande (en lettres moulées s.v.p.)

 

Signature du chef de la division

 

Date (YYAA-MM-DJ)

GILLIAN WELTON

 

 

►

 

 

 

 

 

 

 

 

 

No criminal record

A possible criminal record #:

►

Last entry:

►

Aucun casier judiciaire

Numéro du casier judiciaire possible :

Dernière entrée :

An outstanding warrant/charge held by:

►

 

 

 

 

Auteur du mandat non exécuté/accusation en instance :

 

 

 

 

SIGNATURES

►Approved Approuvée

Security Intelligence Officer

Agent de renseignements de sécurité

►

 

 

 

 

 

The individual has been advised. – Le demandeur a été informé de la décision.

 

 

Not approved

 

►

 

Yes

 

No

By:

 

 

 

 

 

 

 

 

Non approuvée

 

 

Oui

 

Non

Par :

 

 

 

 

 

 

 

Date

Institutional Head

 

 

Date

Visit Review Board

Date

(YYAA-MM-DJ)

Directeur de l’établissement

 

 

(YYAA-MM-DJ)

Comité des visites

(YYAA-MM-DJ)

 

 

 

►

 

 

 

 

►

 

 

CSC/SCC 1279 (R-05-12) (Word Version) XP

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Part no. 1 for submitting csc clearance

2. The next step is usually to complete all of the following blank fields: If so provide names Si oui, Do you have any reason to believe, Are you relatedassociated to an, Yes Oui Yes Oui Yes Oui, No Non No Non No Non, If you have answered YES to any of, Une fois que les sections A à E, E SIGNATURE When sections A to E, En soumettant la présente demande, Applicants signature Signature du, F FOR OFFICE USE ONLY RÉSERVÉ AU, Institutional tour for Forum of, Gillian Welton, No criminal record An outstanding, and Aucun casier judiciaire Auteur du.

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