Cbp Form 3078 - Application For Identification Card - Department Of Homeland Security
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1
2DEPARTMENT OF HOMELAND SECURITY
U.S. Customs and Border Protection
APPLICATION FOR IDENTIFICATION CARD
19 U.S.C. 66, 1551, 1555, 1565, 1624, 1641;
OMB No.1651-0008
19 CFR 112.42, 118, 122.182, 146.6
Exp. 02-28-2018
2. DATE OF THIS APPLICATION
1. TYPE OF ACTIVITY REQUIRING IDENTIFICATION CARD
CBP
Foreign
Broker's
Cartman/
Warehouse Officer
Container Station
CES
Security Area
Trade Zone
Employee
Lighterman
Employee
or Employee
Employee
Identification
Employee
3. NAME (Last, First, & Middle)
4. SOCIAL SECURITY NUMBER
5. LIST ANY OTHER NAMES YOU HAVE EVER BEEN KNOWN BY (Nicknames, aliases, etc.)
6. DATE OF BIRTH
7. HOME ADDRESS (Number, Street, City, State, and ZIP Code)
8. NAME AND ADDRESS OF PRESENT EMPLOYER
9. HOME PHONE NUMBER
10. BUSINESS PHONE NUMBER
11. PLACE OF BIRTH (City, County, State, and Country)
12. HEIGHT
13. WEIGHT
14. COLOR HAIR 15. COLOR EYES
16. VISIBLE SCARS OR MARKS
17. U.S. COAST GUARD PORT SECURITY CARD NUMBER
18. U.S. MERCHANT MARINE CARD NUMBER
19. HAVE YOU EVER APPLIED FOR CARD IN ITEM 17 OR ITEM
20. HAS APPLICATION FOR EITHER CARD IN ITEM 17 OR 18 BEEN
18?
DENIED?
(Skip Items 20 and 21)
(If Yes, explain in Item 21)
(Skip Item 21)
YES
NO
YES
NO
21. EXPLANATION OF APPLICATION DENIAL
22. LIST ALL RESIDENCES DURING THE LAST 5 YEARS (List in reverse order, beginning with the present address)
DATES
Number and Street
City
State
From
To
PRESENT
23. HAVE YOU EVER SERVED IN THE ARMED SERVICES OF THE U.S.?
24. BRANCH OF SERVICE
(Skip Items 24-28)
YES
NO
27. TYPE OF DISCHARGE
25. DATES OF SERVICE
26. SERIAL NUMBER
28. IF DISCHARGE WAS OTHER THAN HONORABLE, EXPLAIN IN FULL DETAIL
29. HAVE YOU EVER APPLIED FOR AN IDENTIFICATION CARD WITH
(If Yes, explain details)
YES
NO
U.S. CUSTOMS AND BORDER PROTECTION?
CBP Form 3078 (04/08)
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