HTML version of the form: Confidential Report

Warning

In accordance with National Defence Security Orders and Directives (NDSOD), form DND 2839-E - Confidential Report is designated "Protected B" information once completed.

Completed "Protected B" forms must not be saved unencrypted on any network and workstation drive or storage media. "Protected B" forms, when completed, must be encrypted using the Department of National Defence (DND) issued Public key infrastructure (PKI) Smartcard. Failure to respect this requirement will result in a breach of security and sanctions shall be applied in accordance with the policy.

Protected B (When completed)

Confidential Report

When completed, forward to: Assistant Deputy Minister (Review Services), Attention: Defence Ethics Programme/Conflict of Interest (DEP/COI), National Defence Headquarters (NDHQ), MGen George R. Pearkes Building, Ottawa ON K1A 0K2. Secure email at: COIDEP-CIPED@forces.gc.ca.

• Service number or Personal Record Identifier (PRI)
• Rank or classification
• Surname, name and initials
• Canadian Armed Forces (CAF) class of service
  • Regular
  • Reserve
    • A
    • B
    • C
• Position
• Command, formation or base, or branch or division
• Telephone (Office)
• Address (where you want the DEP/COI reply letter to be sent)
• Telephone (Other)
• E-mail
• Please send my letter in
  • English
  • French

Note: If space below is insufficient, attach a second page.

• In compliance with the Defence Administrative Orders and Directives (DAOD) 7021 series, I hereby disclose the following (a) non-exempt assets and liabilities, AND/OR (b) outside employment and activities, AND/OR (c) gifts, hospitality and other benefits, AND/OR (d) circumstances of any kind which may give rise to a COI. I fully understand that I may have to divest myself of, curtail, or modify such assets, liabilities, activities or benefits if it is determined that they give rise to a conflict of interest in respect of the duties and responsibilities of the position offered to or occupied by me.

Important:

1. For Regular Force and Class B or C Reserve Force seeking Civilian Employment:
   • Attached is my CO’s permission IAW QR&O 19.42 - Civil Employment.
2. For all CAF members - by signing this form, I understand and acknowledge the following:
   • that any injury or illness incurred while engaging in civilian employment or undertaking that compromises my ability to meet Minimum Operational Standards Related to Universality of Service may result in restrictions being imposed upon me and may result in release from the CAF;
   • that an injury or illness suffered as a result of the civilian employment or undertaking may not be eligible for certain benefits; and
   • that any liability I might incur in my outside activity must be covered under my own insurances and conform to my professional order’s requirement (if applicable).

• Signature
• Date

Privacy Act Statement: The information you provide on this document is Protected B once completed and will be stored in personal information bank PIB PSE 915 - Values and Ethics Codes for the Public Sector and Organizational Code(s) of Conduct. Personal information that you provide is protected under the provisions of the Privacy Act.

Formulaire disponible en Français - DND 2839-F

DND 2839-E (08-2016) CLF 2.0
Design: Forms Management 613-995-9944 / 613-947-8944

Protected B (When completed)

Email: COIDEP-CIPED@forces.gc.ca