Initial Renewal Airport Security Badging Office 700 Catalina Drive, Suite 110 Daytona Beach, Florida 32114 (386)-248-8030 Application for Airport SIDA Identification Media Last Name First Name Middle Name Social Security # (Voluntary) of Birth State / Country of Birth - - / / Home Address Email Address City State Zip Code Primary Contact Phone # Sex Height Weight Eye Color Hair Color ( ) - Driver License # State License Expiration / / Company Name Company Phone Job Title Have you EVER been convicted, entered a plea of nolo contendre (no contest), or had adjudication withheld for any felony, misdemeanor, infraction, or any violation of the law? Include in this section traffic and motor vehicle infractions as well. Yes No If yes, list in the space provided below. The only violations which may be excluded from this list are parking violations. A conviction will not necessarily disqualify you from consideration for a badge. However, Volusia County Airport Division (VCAD) may not issue a badge if incorrect, incomplete, or false information is provided. VCAD reserves the right to deny a badge application for any reason. Violation City County and State Case Disposition Version 16.1 10.16 DAYTONA BEACH INTERNATIONAL AIRPORT 1
Disqualifying Offenses 1. Forgery of certificates, false marking of aircraft, and other aircraft registration violations; 49 U.S.C. 46306. 2. Interference with air navigation; 49 U.S.C. 46308. 3. Improper transportation of a hazardous material; 49 U.S.C. 46312. 4. Aircraft piracy; 49 U.S.C. 46502. 5. Interference with flight crew members or flight attendants; 49 U.S.C. 46504. 6. Commission of certain crimes aboard aircraft in flight; 49 U.S.C. 46506. 7. Carrying a weapon or explosive aboard an aircraft; 49 U.S.C. 46505. 8. Conveying false information and threats; 49 U.S.C. 46507. 9. Aircraft piracy outside the special aircraft jurisdiction of the United States; 49 U.S.C. 46502(b). 10. Lighting violations involving transporting controlled substances; 49 U.S.C. 46315. 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. 46314. 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 i. Willful destruction of property; ii. Importation or manufacture of a controlled substance; iii. Burglary; iv. Theft; v. Dishonesty, fraud, or misrepresentation; vi. Possession or distribution of stolen property; vii. Aggravated assault; viii. Bribery; or ix. 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 aforementioned criminal acts. VCAD has the right to deny a badge for reasons other than those listed above. Be advised that Federal regulations under 49 CFR 1542.209(1) impose a continuing obligation to disclose to the Airport within 24 hours if you are convicted of any disqualifying criminal offense that occurs while you have unescorted access authority. I have read the above list of disqualifying crimes and hereby certify that within the last ten (10) years prior to the date this document was executed, I have not been convicted or found to be not guilty by reason of insanity of any of the above crimes. 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). Applicant Version 16.1 10.16 DAYTONA BEACH INTERNATIONAL AIRPORT 2
Citizenship Statement (Required) Other Names Used (aliases, maiden names) Country of Birth: Current Residence (city, state, zip) Same as Above Country of Citizenship: I attest, under penalty of perjury, that I am one of the following: A citizen of the United States* A Lawful Permanent Resident** An alien with work authorization*** * US Citizens must complete this section completely. US citizenship is by: birth naturalization other (specify): If you are a US citizen by any means other than birth, you must provide an original Naturalization Certificate or US Passport. ** All lawful permanent residents must complete this section and provide original resident alien card. Alien Registration Number: A *** All aliens with work authorization must complete this section and provide original Employment Authorization Document (EAD) card. Employment Authorization Document Number: Expiration : I understand that federal law provides for imprisonment and/or fines for falsely claiming to be a United States Citizen, or for making false statements, or for using false documents in connection with the completion of this form. (see Section 1001, Title 18, United States Code) : : Applicant s Rights You have the right to request a copy of your individual criminal record received from the FBI and that request must be in writing. You must notify the Airport Security Coordinator (ASC) or designee within 30 days in writing of your intent to correct any information you believe to be inaccurate. The Airport must obtain a copy, or accept a copy from you, of the revised FBI record, or a certified true copy of the information from the appropriate court, prior to granting unescorted access authority. The ASC is the individual point of contact if you have any questions about the results of the Criminal History Record Check (CHRC). Volusia County Privacy Statement Pursuant to the requirements of Public Law 93-579 (Privacy Act of 1974), notice is hereby given that the authority to collect information requested on the Daytona Beach International Airport Badge Application for a new and/or renewal Airport Identification Badge is 42 U.S.C. 301, Reorganization Plan No. 1 of 1953; and U.S.C. Section 552a. Disclosure of the requested information is not mandatory. Applicant is advised, however, that the principal purpose for collecting the information is to enable the sponsor/employer and/or the Airport to conduct a background investigation and thereby determine whether the applicant meets the criteria required for the issuance of a SIDA badge. The identification badge will not be issued unless the background investigation is completed and the employee meets the required criteria. The information may also be used, when deemed appropriate, in a proceeding to revoke or suspend the identification badge. The information collected and contained in the applicant s file may be provided to any and all employees of the Airport who have a need for the records in the performance of their duties. Version 16.1 10.16 DAYTONA BEACH INTERNATIONAL AIRPORT 3
TSA Privacy Act Notification Authority: 49 U.S.C Sections 114, 44936 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 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 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 an STA, 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 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. Applicant Responsibilities 1. All identification badges remain the property of VCAD. The badge is non-transferable to any other person. 2. The badge must be displayed on the upper portion of the body, on the outermost garment, and must be clearly visible while in the Secured Area, SIDA, or AOA. The badge must be clearly visible and recognizable when worn. If a container or holder is used, that container or holder must be uncolored and clear. The badge is not to be defaced in any manner. No other markings or stickers may be added to the badge. 3. All individuals issued an identification badge must challenge and, if applicable, provide escorts according to training. 4. Identification badges are issued for security purposes and are subject to the rules and regulations of the Federal Aviation Administration, the Transportation Security Administration, County of Volusia, and the sponsoring tenant. 5. Expiring badges must be renewed prior to the expiration date on the face of the badge. Door access is automatically revoked on the expiration date. Badges are valid for up to one (1) year. Airport driving training is required annually. Contractor badges are issued for the duration of the project, up to one (1) year. 6. Recurrent SIDA training is required annually and must be completed within the three-months prior to badge expiration. If the recurrent class is not taken prior to the expiration date, the next available full SIDA class must be taken. If training is not taken prior to the expiration date, the expired badge must be returned to the Airport Security Office. 7. SIDA badgeholders who do not renew expired badges within thirty (30) days of expiration will need to complete a new badge application, undergo a fingerprint-based CHRC, and take the full SIDA class before a new badge will be issued. Use of an expired badge is a violation and may result in denial of badge renewal, criminal penalties, and/or civil penalties. 8. The Airport Security Office must be notified immediately of any lost/stolen badges. A fee of $50 is charged for a first lost/stolen badge. A fee of $100.00 is charged for a second lost/stolen badge or one not returned upon termination of employment. If a badge holder has lost two badges, requests for additional replacements must be approved by the ASC or Director of Aviation. 9. Badgeholders must immediately notify the Airport Security Office if they become aware that any access point, access control system or a component thereof has been breached, compromised, or threatened by any means. 10. Please note that badge applicants will need to provide two forms of identification when submitting their application, one of which is government issued. In addition, one of them must be a photo-id. The preferred forms of identification are a passport or a driver s license and a social security card. Badge applicants who do not have these forms of identification, should contact their employers for acceptable alternate forms. 11. Badgeholders agree to abide by all applicable Federal, state, local, and County of Volusia rules, regulations, laws, ordinances, and training received relative to his/her term of employment or term of lease at the Daytona Beach International Airport. Version 16.1 10.16 DAYTONA BEACH INTERNATIONAL AIRPORT 4
Social Security Certification (NOTE TO APPLICANTS: This section is optional. Only sign if SSN provided on front page) I authorize the Social Security Administration to release my social security number and full name to the Transportation Security Administration, Office of Threat Assessment and Credentialing (TTAC), Attention: Aviation Programs (TSA-19) Aviation Worker Program, 601 South 12th 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 my Social Security records, I could be punished by a fine, imprisonment, or both. of birth Social Security Number Full Name (printed) Authorized Signatory/Manager Approval Section (NOTE TO APPLICANTS: Do Not Sign This Section) Type of Badge Required Other Privileges Required Additional Access Areas Government Armed LEO Non-movement/PSR Driving Concourse Air Cargo Terminal Tenant Movement Area Driving Customs/FIS Airfield Tenant Escort Domestic ramp Contractor No additional privileges International ramp Specific Door Access Requested: I understand that our company is responsible for this individual s ID Media (airport badge) and hereby agree to the following provisions and charges: Provision #1 Termination of Employment and/or Expired Badge: Airport badge shall be returned within five (5) business days upon termination of employment and/or from badge expiration date otherwise a charge of $100.00 will be assessed. Provision #2 Lost and/or Broken Badge: A lost and/or misplaced airport badge shall be reported immediately upon knowledge of loss. A fee of $50 is charged for a first lost/stolen badge. A fee of $100.00 is charged for a second lost/stolen badge. A $15 fee will be assessed for a broken badge. The same $15 fee may apply to badges that are unreadable. As a designated and trained Authorized Signatory, I understand and accept that any badged individual I have authorized to hold Daytona Beach International Airport (DAB) identification media who commits a security violation at DAB, as determined by the Airport or the Transportation Security Administration, may be assessed a civil penalty (monetary fine) and/or have access privileges revoked. The civil penalty and/or access revocation may be directed at the individual and/or the company for which he/she works. I understand it is my responsibility to immediately notify the Airport Security Office via telephone or in person any time an individual s access authority is to be limited or revoked, an individual s ID Media has been lost or stolen, or if I believe any component of the airport s security system has been compromised in any way. This is to be followed up by written notification to the Airport Security Coordinator within 24 hours. All coordination shall be with the Airport Security Office at the Daytona Beach International Airport. I understand it is my responsibility to report to the Airport Security Office information as it becomes available that indicates an individual with unescorted access authority may have a disqualifying criminal offense. Additionally, I understand that it is my responsibility to report to the Airport Security Office when the individual has an expired form I-9 employment eligibility verification document issued by the U.S. Citizenship and Immigration Service and is no longer authorized to work, if applicable. For Authorized Signatory ONLY Applicants do not sign this section Company Print Name Version 16.1 10.16 DAYTONA BEACH INTERNATIONAL AIRPORT 5
For Office/Airport Security Coordinator s Use Application received: / / Fingerprint date: / / STA Input: / / Secured Area/SIDA Background Investigations CHRC: Disqualifying Conviction: Case Number: Yes No Completed: / / STA: Approved: Number: Yes No Completion : / / of submitting agent: : / / Airport Security Coordinator Approval This applicant may be badged: Yes No : : / / DAB SIDA Training : / / Badgeholder Privileges Areas of Access/Privileges Granted (check all applicable) FIS Ramp FIS Building Air Cargo SIDA Domestic Ramp Sterile Area/Concourse Escort Type of Badge Issued (check all applicable) Government (non-leo) Government (LEO) Terminal Tenant Contractor Airfield Tenant Driving Privileges Granted (check one if applicable) Movement Non-movement/PSR of driver training: / / Badge Status Issued by: Trusted Agent Badge Number: issued: / / Expiration date: / / Lost: / / returned: / / Version 16.1 10.16 DAYTONA BEACH INTERNATIONAL AIRPORT 6