CHARLESTON COUNTY AVIATION AUTHORITY APPLICATION FOR AIRPORT AOA/PUBLIC AREA BADGE

Transcription

1 STA APPROVAL CHARLESTON COUNTY AVIATION AUTHORITY APPLICATION FOR AIRPORT AOA/PUBLIC AREA BADGE Print or Type all Information SECTION I -- APPLICANT SSN: NAME (Last, First, Middle): HOME ADDRESS (Street, City, State, Zip): JOB TITLE: Mailing Address, if different: WORK HOME List any nicknames, aliases or previously used names: Date of Hire: SUPERVISOR: Height Weight Hair Eyes Gender DATE OF BIRTH: DRIVERS LICENSE NO.: STATE: DL EXPIRATION: I understand a background check must be performed and agree that all former employers may furnish my employer information regarding my service, character and reason for leaving former employment. I hereby release such former employer(s) from all liability on account of providing such information. By signing below I certify that the information provided on this form is truthful and accurate. Applicant Signature Date of Application: NOTE: You will be subject to employment history verification, fingerprint submission and criminal history records check. You must disclose any disqualifying convictions within the past 10-year period (see list of crimes on next page). SECTION 2 - TO BE COMPLETED BY CERTIFICATION OFFICIAL CERTIFICATION: I acknowledgeresponsibility for any FAA/TSA fines levied against CCAA which were caused by the failure of one of our employees to adhere to the Charleston International Airport Security Program. A review and verification of applicant's 5-year employment history has been conducted and no condition was discovered which would cause AOA access to be denied (Summary listed on next page). Escort Authority? Escort Justification: Signature of Certification Official Date: SECTION 3 - CHS OPERATIONS OFFICE Color: Employee Contractor Work Area: Access Levels: Public Areas East Side & Airfield Airside Driver? Date of Driver Class: Test Score: Contractor to: Issue Date: Expire Date: NCIC: DL status AOA Security Training Date: Issued by: SECTION 4 - Signature below acknowledges receipt of CHS ID ID Badge # Signature Date Received PIN Revised 06/15

2 CHARLESTON INTERNATIONAL AIRPORT -- EMPLOYMENT HISTORY INVESTIGATION SUMMARY Applicant Name: List employers for the past 5 years, listing current airport employer first. Include dates, addresses and phone numbers. Include schooling and unemployed periods and explain any gaps in employment record. Use additional sheets if needed. Certification must include verification information for 5 years prior to date of application and must be completed by company or agency applying for access privilege for this individual. Gaps of 12 months or more must be fully explained.

3 CHARLESTON INTERNATIONAL AIRPORT -- AOA/PUBLIC AREA ID REPLACEMENT REPLACEMENT ID# has been Signature of Badge Holder: LOST STOLEN NEW ID# Lost/Stolen ID Fee$ Replacement # ID# has been Signature of Badge Holder: LOST STOLEN NEW ID# Lost/Stolen ID Fee$ Replacement # ID# has been Signature of Badge Holder: LOST STOLEN NEW ID# Lost/Stolen ID Fee$ Replacement # Revised 06/15

4 Privacy Act Notice Security Threat Assessment Form Privacy Act Notice Authority: 49 U.S.C., authorizes the collection of this information Purpose: The Department of Homeland Security (DHS) will use the biographical information to conduct a security threat assessment to evaluate 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 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 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 s records to ensure the validity of your name and SSN. Routine Uses: This information may be shared 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 Use 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 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). Revised 05/01/2015

5 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 th Street, Arlington, VA 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. Social Security Number: Date of Birth: Full Name: Date: Revised 05/01/2015

6 CHARLESTON COUNTY AVIATION AUTHORITY CHARLESTON INTERNATIONAL AIRPORT FAR Part (d) Disqualifying Criminal Offenses An individual has a disqualifying criminal offense if the individual has been convicted, or found not guilty of by reason of insanity, of any of the disqualifying crimes listed in this paragraph (d) in any jurisdiction during the 10 years before the date of the individual's application for unescorted access authority, or while the individual has unescorted access authority. The disqualifying criminal offenses are as follows (1) Forgery of certificates, false marking of aircraft, and other aircraft registration violation; 49 U.S.C (2) Interference with air navigation; 49 U.S.C (3) Improper transportation of a hazardous material; 49 U.S.C (4) Aircraft piracy; 49 U.S.C (5) Interference with flight crew members or flight attendants; 49 U.S.C (6) Commission of certain crimes aboard aircraft in flight; 49 U.S.C (7) Carrying a weapon or explosive aboard aircraft; 49 U.S.C (8) Conveying false information and threats; 49 U.S.C (9) Aircraft piracy outside the special aircraft jurisdiction of the United States; 49 U.S.C (b). (10) Lighting violations involving transporting controlled substances; 49 U.S.C (11) Unlawful entry into an aircraft or airport area that serves air carriers or foreign air carriers contrary to established security requirements; 49 U.S.C (12) Destruction of an aircraft or aircraft facility; 18 U.S.C. 32. (13) Murder. (14) Assault with intent to murder. (15) Espionage. (16) Sedition. (17) Kidnapping or hostage taking. (18) Treason. (19) Rape or aggravated sexual abuse. (20) Unlawful possession, use, sale, distribution, or manufacture of an explosive or weapon. (21) Extortion. (22) Armed or felony unarmed robbery. (23) Distribution of, or intent to distribute, a controlled substance. (24) Felony arson. (25) Felony involving a threat. (26) Felony involving (a) Willful destruction of property; (b) Importation or manufacture of a controlled substance; (c) Burglary; (d) Theft; (e) Dishonesty, fraud, or misrepresentation; (f) Possession or distribution of stolen property; (g) Aggravated assault; (h) Bribery; or (i) Illegal possession of a controlled substance punishable by a maximum term of imprisonment of more than 1 year. (27) Violence at international airports; 18 U.S.C. 37. (28) Conspiracy or attempt to commit any of the criminal acts listed in this paragraph (d). I certify that I have not been convicted of, nor found not guilty by reason of insanity, of any of the listed crimes in the past 10 years prior to the date of this application. Applicant Signature Date

7 SECURITY THREAT ASSESSMENT FORM (STA) The Transportation Security Administration is directing airport operators to obtain biographical data of persons that have been issued or are applying for a CHS ID badge. The TSA will conduct a threat assessment with the information. Falsification or refusal to provide information shall result in revocation of badge or badge application. Badge Applicant Last Name: Please Print First Name: Middle Name: Gender: DOB (MMDDYYYY) SSN: Country of Birth Alien Registration # Country of Citizenship Non-Immigration Visa # Passport # Country Issuing Passport Employee Signature: Company Certification Official Signature: 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 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) Date STA Submitted Date STA Received 06/15

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