Fillable Renewal Badge Application Form printable pdf download

SALT LAKE CITY DEPARTMENT OF AIRPORTS

GROUND TRANSPORTATION

RENEWAL BADGE APPLICATION

Badge #

Person ID #

Present this application along with two (2) forms of identification (Refer to the I‐9 List of

SECTION 1

Acceptable Documents.) Type or print legibly using black or blue ink. Complete all applicable

APPLICANT INFORMATION

sections.

Last Name

First Name

Middle Name

Other Names Used (Include Maiden, Nickname, or Aliases)

Last Name

First Name

Middle Name

Last Name

First Name

Middle Name

Last Name

First Name

Middle Name

Race/Ethnicity

 Asian  Black  Hispanic, Latino  Native American  White  Unknown  Other (Please List) _____________________________

Date of Birth (

Gender

Hair Color

Eye Color

Height (Feet/Inches)

Weight (Lbs.)

MM/DD/YYYY)

 Male  Female

/ /

Driver’s License or State ID Card Number

State

Home or Cell Phone Number

Passport Number

Passport Country

(

)

Mailing Address

City

State

Zip

Place of Birth

Citizenship

City

State

Country

IF YOU ARE A U.S. CITIZEN NOT BORN IN THE U.S.

IF YOU ARE NOT A U.S. CITIZEN

 US Passport

 Non‐Immigrant Visa

No.

 Birth Abroad Certificate

 I‐94 Form

No.

(Form DS1350 or FS545)

 Certification of Naturalization

 Certificate of Citizenship

 Other

No./ Type

(N‐550)

(N‐560)

Alien Registration Number: (Applies to both categories above)

SECTION 2 ‐ PRIVACY ACT NOTICE

Authority: 6 U.S.C § 1140, 46 U.S.C § 70105; 49 U.S.C. §§ 106, 114, 5103a, 40103 (b)(3), 40113, 44903, 44935‐44936, 44939, and 46105; the Implementing

Recommendations of the 9/11 Commission Act of 2007, § 1520 (121 Stat. 444, Public Law 110‐52, August 3, 2007); and Executive Order 9397, as

amended.

Purpose: The Department of Homeland Security (DHS) will use the biographical information to conduct a security threat assessment. Your fingerprints and

associated information will be provided to the Federal Bureau of Investigation (FBI) for the purpose of comparing your fingerprints to other fingerprints in

the FBI’s Next Generation Identification (NGI) system or its successor systems including civil, criminal, and latent fingerprint repositories. The FBI may

retain your fingerprints and associated information in NGI after the completion of this application and, while retained, your fingerprints may continue to be

compared against other fingerprints submitted to or retained by NGI. DHS will also transmit your fingerprints for enrollment into the US‐VISIT Automated

Biometrics Identification System (IDENT). If you provide your Social Security Number (SSN), DHS may provide your name and SSN to the Social Security

Administration (SSA) to compare that information against SSA records to ensure the validity of the information.

Routine Uses: In addition to those disclosures generally permitted under 5 U.S.C 522 a(b) of the Privacy Act, all or portion of the records or information

contained in this system may be disclosed outside DHS as a routine use pursuant to 5 U.S.C. 522a(b)(3) including with third parties during the course of a

security threat assessment, employment investigation, or adjudication of a waiver or appeal request to the extent necessary to obtain information

pertinent to the assessment, investigation, or adjudication of your application or in accordance with the routine uses identified in the TSA system of records

notice (SORN) DHS/TSA 002 Transportation Security Threat Assessment System. For as long as your fingerprints and associated information are retained in

NGI, your information may be disclosed pursuant to your consent or without your consent as permitted by the Privacy Act of 1974 and all applicable

Routine Uses as may be published at any time in the Federal Register, including the Routine Uses for the NGI system and the FBI’s Blanket Routine Uses.

Disclosure: Furnishing this information (including your SSN) is voluntary; however, if you do not provide your SSN or any other information requested, DHS

may be unable to complete your application for a security threat assessment.

Initials X ______________

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Ph: 801‐575‐2423 | Fax: 801‐575‐2377 | P.O. Box 145550, Salt Lake City,