Air Carrier & Exempt Id Badge Renewal / Replacement Form (Page 2 of 2) in pdf

UPDATED BADGE HOLDER INFORMATION

Company Name : __________________________________________________________________________ PHL Badge # ____________________________

Last Name: _______________________________________________Suffix: _______ First Name:________________________________ MI: ______________

Aliases: ___________________________________________________________________________________________________________________________

Social Security Number: ____________-_________-_____________

Date of Birth (mm/dd/yyyy): __________/__________/________________

Country of Birth (country name): ______________________________________ City and State of Birth: ___________________________________________

Current Mailing Address:________________________________________________________________________ City: ________________________________

County: __________________________State: _______________ Zip Code: __________________ Contact Phone Number _______-________-___________

Electronic Mail Address (e-mail) (Optional):___________________________________________________________________@__________________________

Gender:

Male

Female

Other

Height: ________ft. ________ in.

Weight: _________ lbs.

Natural Hair Color:

Brown

Black

Blonde

Red

Gray

White

Bald

Natural Eye Color:

Black

Blue

Brown

Hazel

Green

Gray

Race:

Caucasian

Black

Asian

Hispanic/Latino

Native American

Unknown

The Privacy Act of 1974

5 U.S.C. 552a(e)(3)

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 City of Philadelphia and the Department of Homeland Security (“DHS”), will use the biographical information to conduct security threat assessment to evaluation your

eligibility for the program to which you are applying. Your fingerprints and associated information/biometrics 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\biometrics 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 the fingerprints for enrollment into the US-VISIT’s Automated Biometrics Identification

Systems (IDENT). If you provide your Social Security Number (SSN), DHS may provide your name and SSN to the Social Security Administrations (SSA) to compare that information

against SSA’s records to ensure the validity of your name and SSN.

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

be disclosed outside DHS as a routine use pursuant to 5. U.S.C 522 a(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 Transportation Security Threat Assessment System

(T-STAS), DHS/TSA 002. For as long as your fingerprints and associated information/biometrics 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 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 identification media.

The information I have provided is true, complete and correct to the best of my knowledge and belief and is provided in good faith. I understand that a knowing and willful false statement

can be punished by fine or imprisonment or both (see Section 1001 of Title 18 of the United States Code)

I authorize the Social Security Administration to release my Social Security Number and full name to the Transportation Security Administration, Office of Intelligence and Analysis (OIA):

Aviation Programs (TSA-10)/Aviation Worker Program, 601 South 12

Street, Arlington VA 20598.

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.

Country of Citizenship: ________________________________________________

Alien Registration Number (if applicable): _____________________________________

Passport Country (optional): ____________________________________________ Non-Immigrant Visa Number (if applicable): ____________________________________

Passport Number (optional): _______________________________________________________________ Passport Expiration Date:________/________/________________

Print Name: _________________________________________________________ Social Security #: ________ - ________ - ___________

DOB: _______/________/________

Signature: ____________________________________________________________________________________________ Date: ______________________________________

For Compliance with SD 1542 04 08J issued 09.02.2015