Fillable Renewal Badge Application Form (Page 2 of 2) in pdf

SECTION 3

SOCIAL SECURITY NUMBER RELEASE



I authorize the Social Security Administration to release my Social Security Number and full name to the Transportation Security Administration, Office

of Transportation Threat Assessment and Credentialing (TTAC), Attention: Aviation Programs (TSA‐19)/Aviation Worker Program, 601 South 12

Street,

Arlington, VA 22202. I am the individual to whom the information applies and want this information released to verify that my SSN is correct. I know that if

I make any representation that I know is false to obtain information from Social Security records, I could be punished by a fine or imprisonment or both.



I do not authorize the release of my Social Security Number. (NOTE: This may delay the Security Threat Assessment process, but will not disqualify

you from receiving a badge. Printed name and signature are still required.)

Printed Name:

First

Middle

Last

Social Security Number:

_____

Applicant’s Signature X _______________________________________________________________________________________________________

SECTION 7

TERMS AND CONDITIONS OF BADGE HOLDER

This section must be completed after training is complete.

Security Responsibility Agreement

I will not allow anyone to use my Airport ID badge nor will I use

another individual’s badge. I agree to return the Airport ID Badge if



I will swipe my Airport ID badge and enter a PIN each time I enter the CASS‐

my employment status changes and I no longer have a need for an

controlled gate(s) leading to the commercial lanes.

Airport ID badge. I understand that there is a $100 fee for a non‐



I will not allow unauthorized access through a controlled access point

returned badge. I agree to report any lost or stolen Airport ID

(piggybacking).

Badges to the Airport, and also understand there is a $50



I will not give out confidential security information.

replacement fee for a lost/stolen badge. There is also a $25 fee to



I will wear the Airport ID badge on my outermost garment when operating at the

replace a badge that has been defaced with stickers, pins, etc.

Airport.

(Fees are subject to change.)

I understand and acknowledge that violation of the Airport’s

Initials X __________

Security Program will result in administrative action to include

Airport ID badge reinstatement fees, retraining, possible TSA civil

penalties, and could also result in permanent revocation of my

badge.

Initials X __________

IDENTIFICATION BADGE RECEIVED BY

This section must be completed at time of badge issuance.

Applicant’s Signature X ______________________________________________________________________________ Date _______________

I understand that when no longer required, my badge must be immediately returned to the Airport’s Access Control Office or a $100 non‐returned badge

fee will be assessed. Initials X __________

SECTION 8

ACCESS CONTROL USE ONLY

Payment Type:

Amount:

Received By

 $65  Other: __________

 Cashier Check  Company Check  Credit Card  Money Order

Threat Assessment Date

CHRC Results Date

CHRC Case Number

 STA Pass  STA Fail

 Lost  Voided

Card Number

Training Date

Expiration Date

PIN Number

Card Number:

Lost Fee Paid:  $50  N/A

Refund Amount Due

Lost Card No./Returned Date

 $0 (Expired)  $25  $50

 Cashiers Check  Company Check  Credit Card  Money Order

Warrants:  Cleared  Referred (Verified By:________________ ) DL Verification:  Valid  Suspended (Verified By:________________ )

I certify that I have verified the identity and work authorization of the applicant.

X ____________________________________________________

___________________

Verified By

Date

Comments

Issued By / Date

January 2016

2 of 2

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

Renewal Badge Application Form Page 2

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