HTML version of the form: Request for a Waiver or Reduction of Post - Employment Restrictions

Warning

In accordance with National Defence Security Policy, the form titled DND 2841-E- Request for a Waiver or Reduction of Post-Employment Restrictions 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)

Request for a Waiver or Reduction of Post - Employment Restrictions

When completed, forward to: Assistant Deputy Minister (Review Services), Attention: DEP/COI, NDHQ, MGen George R. Pearkes Building, Ottawa ON K1A 0K2. Secure email at: ++COI DEP - CI PED@ADM(RS) DEP@Ottawa-Hull

• Service number or Personal Record Identifier (PRI)
• Rank or Classification
• Surname, Name and Initials
• Command, Formation or Base, or Branch or Division
• Position
• Current or last position occupied
• Public service retirement or Cessation of employment date
• Canadian Forces (CF) Retirement date
• CF Release date
• Accepted Cash-Out or Terminal Benefits:
  • Yes
  • No
• Telephone (Office)
• Address (where you want the Defence Ethics Programme/Conflict of Interest (DEP/COI) reply letter to be sent)
• Telephone (Other)
• Email

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

1. Explain the circumstances under which the termination of your employment or service occurred or will occur:
2. Describe your general employment prospects:
3. Describe the significance to the Government of Canada of the information you possess or possessed, by virtue of your employment in the DND or service in the CF, that is not generally available to the public:
4. Explain how a rapid transfer of your knowledge and skills from the Government of Canada to private, other governmental or non- governmental sectors would be desirable:
5. Explain whether or not there is a possibility that your prospective employer could gain an unfair commercial advantage by hiring you:
6. Explain any authority or influence you may possess or may have possessed while in service:
7. Describe the special circumstances that in your opinion would warrant a waiver or reduction of post-employment restrictions:

Privacy Act Statement: The information you provide on this document is Protected B once completed and will be stored in personal information banks DND PPE 864 - Conflict of Interest and Post-Employment Code - Military for CF members and DND PPE 915 Conflict of Interest and Post-Employment Code - Civilian for DND employees. Personal information that you provide is protected under the provision of the Privacy Act.

In accordance with paragraph 8(2)(a) of the Privacy Act, personal information may be disclosed for a use consistent with the purpose for which it was obtained or compiled. For the purpose of the information collected in this Request for a Waiver or Reduction of the Limitation Period form, information may be disclosed to your new employer or supervisor, or both.

I agree to the disclosure of this personal information in accordance with paragraph 8(2)(a) of the Privacy Act.

• Signature
• Date

DND 2841-E (11-2012) CLF 2.0

Design: Forms Management 613-957-6899 / 613-957-6906

Formulaire disponible en Français - DND 2841-F

Protected B (When completed)

Courriel : COIDEP-CIPED@forces.gc.ca