APPLICANT NAME:

BADGE TYPE:

AIRPORT IDENTIFICATION BADGE (AIB) APPLICATION

LAST NAME

FIRST NAME

MIDDLE NAME

SUFFIX

ALIAS LAST NAME

ALIAS FIRST NAME

ALIAS MIDDLE NAME

PERSONAL PHYSICAL ADDRESS

CITY

STATE

COUNTRY

ZIP

PRIMARY PHONE

CELL / WORK PHONE

PRIMARY EMAIL

DATE OF BIRTH: MM/DD/YYYY

COUNTRY OF BIRTH

STATE OF BIRTH (If USA)

CITIZENSHIP

SOCIAL SECURITY NUMBER

PASSPORT NUMBER

PASSPORT ISSUING COUNTRY

DRIVERS LICENSE NUMBER

STATE

EXP DATE

ALIEN REGISTRATION NO.

I-94 ARRIVAL/DEPARTURE FORM

NON IMMIGRANT VISA CONTROL NUMBER

CERTIFICATE OF NATURALIZATION NUMBER

CERTIFICATION OF BIRTH ABROAD DS-1350

PAGE 1 of 8 APPLICANT INITIAL: __________ DATE: _______

APPLICANT NAME:

BADGE TYPE:

ETHNICITY

GENDER

HEIGHT (FEET & INCHES)

WEIGHT (POUNDS)

EYE COLOR

HAIR COLOR

EMPLOYER NAME

APPLICANT POSITION

EMPLOYER MAILING ADDRESS:

CITY

STATE

COUNTRY

ZIP

PRIMARY PHONE

CELL / OTHER PHONE

EMPLOYER TYPE

JOB TITLE

BADGE TYPE

NEW

RENEW

DAMAGED

REACTIVATE

LOST/STOLEN 1^stOccurrence

LOST/STOLEN 2^ndOccurrence

LOST/STOLEN 3^rdOccurrence

STA -

CHRC -

PAGE 2 of 8 APPLICANT INITIAL: __________ DATE: _______

APPLICANT NAME:

BADGE TYPE:

LAST NAME

FIRST NAME

MIDDLE NAME

COMPANY NAME

BUSINESS PHYSICAL ADDRESS

CITY

STATE

COUNTRY

ZIP

PRIMARY PHONE

CELL/OTHER PHONE (Authorized Signatory)

PRIMARY EMAIL

· I understand that the company named in this application accepts responsibility to IMMEDIATELY NOTIFY Airport Operations at (602) 273-2036 when the applicant is no longer in good standing (possible termination) or terminates employment with the company. The company WILL CONFISCATE and RETURN the Airport Identification Badge to Airport Operations within 24 hours of termination

· I am the appointed Authorized Signatory Authority for the above organization

· I understand the applicant stated is an employee/authorized member of the organization

· I authorize the to assess my organization for any and all applicable fees associated with Airport Identification Badges as established in the rates and charges

· I acknowledge that ALL Airport Identification Badge(s) remain the property of the and MUST BE RETURNED to the Airport upon demand, resignation, and termination or at any time access is no longer required

· I acknowledge if the Airport Identification Badge(s) is lost or stolen, I will IMMEDIATELY NOTIFY Airport Operations

· I attest that a specific need exists for providing the individual applicant with unescorted access authority

· I attest that the individual acknowledges their security responsibilities under 49 CFR 1540. 105(a)

I understand that _______ is responsible for any violations of 49 CFR-Part 1542 involving the display and use of AOA/SIDA Identification Badge(s) and that _______ is liable for any and all fines that may be levied by the FAA or TSA for these violations.

In accordance with public law 110-161 “…any employer who employs an employee to whom an airport security badge or other identifier used to obtain access to a secure area of an airport is issued before, on, or after the date of enactment of this paragraph and who does not collect or make reasonable efforts to collect such badges from the employee on the date that the employment… is terminated and does not notify the operator of the airport… within 24 hours…shall be liable to the government for a civil penalty not to exceed $10,000.

I ______, certify that ALL information provided in this application is true and correct to the best of my knowledge.

SIGNATURE

DATE:

PAGE 3 of 8 APPLICANT INITIAL: __________ DATE: _______

APPLICANT NAME:	BADGE TYPE:

· This Airport Identification Badge is issued for my INDIVIDUAL USE ONLY and I will not under any conditions allow another individual to use my Airport Identification Badge

· All Airport Identification Badges remain the property of the and MUST BE RETURNED to Airport Operations upon demand, resignation, and termination or at anytime access is no longer required

· If the Airport Identification Badge is lost or stolen, I will immediately notify the Airport Operations

· Any violation of the Rules and Regulations, Transportation Security Administration (TSA) Security Regulations, Federal, State and Local Laws, may result in suspension, revocation, and/or denial of access to the Air Operations Area (AOA) - Secured Areas

· I will remain at Air Operations Area (AOA) gates until fully closed

· I understand and agree to display my Airport Identification Badge on my outer most garments above waist level while on the AOA, SIDA and Secured Areas

· I agree to report any suspicious activities observed on Airport property to airport security, airport management, airport staff or local law enforcement

· I have undergone the required training and fully understand the security procedures and measures required while entering, exiting, and operating on Airport AOA/Secured Areas

· I understand that my Airport Identification Badge will expire two years from the date of issuance, I am aware of the expiration date and will make re-issuance arrangements with Airport Operations

· I understand I have authorized access to gates/doors and that entering any AOA/Secured Area that has not been authorized may result in suspension, revocation and/or denial of access to the AOA/Secured Area


LIST OF ALL ACCESS LEVELS	ACCESS PRIVILEGES

I, , have provided information on this form that is true, complete and correct to the best of my knowledge. I also have provided this information in good faith and authorize the release of this information to the TSA and other Federal, State, and local agencies on an as needed basis.

SIGNATURE

DATE:

PAGE 4 of 8 APPLICANT INITIAL: __________ DATE: ______

APPLICANT NAME:

BADGE TYPE:




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 110-53, August 3, 2007); FAA Reauthorization Act of 2018, §1934(c) (132 Stat. 3186, Public Law 115-254, Oct 5, 2018), and Executive Order 9397 (November 22, 1943), as amended. Purpose: The Department of Homeland Security (DHS) will use the information to conduct a security threat assessment. If applicable, your fingerprints and associated information 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 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 your fingerprints for enrollment into US-VISIT Automated Biometrics Identification System (IDENT). DHS will also maintain a national, centralized revocation database of individuals who have had airport- or aircraft operator- issued identification media revoked for noncompliance with aviation security requirements. DHS has established a process to allow an individual whose name is mistakenly entered into the database to correct the record and have the individual’s name expunged from the database. If an individual who is listed in the centralized database wishes to pursue expungement due to mistaken identity, the individual must send an email to TSA at Aviation.workers@tsa.dhs.gov. Routine Uses: In addition to those disclosures generally permitted under 5 U.S.C. § 552a(b) of the Privacy Act, all or a portion of the records or information contained in this system may be disclosed outside DHS as a routine use pursuant to 5 U.S.C. § 552a(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 TSA system of records notice (SORN) DHS/TSA 002, Transportation Security Threat Assessment System. For as long as your fingerprints and associated information 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: Pursuant to § 1934(c) of the FAA Reauthorization Act of 2018, TSA is required to collect your SSN on applications for Secure Identification Display Area (SIDA) credentials. For SIDA applications, failure to provide this information will result in denial of a credential. For other aviation credentials, although furnishing your SSN is voluntary, if you do not provide the information requested, DHS maybe unable to complete your security threat assessment.

PAGE 5 of 8 APPLICANT INITIAL: __________ DATE: ______

(when you sign the electronic badge application, you are acknowledging below)

“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, Enrollments Services and Vetting Programs, Attention: Vetting Programs (TSA-10)/Aviation Worker Program, 6595 Springfield Center Drive, Springfield, VA 20598-6010."

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.

Signature: Date of Birth:

SSN and Full Name:


“SCREENING NOTICE: Any employee holding a credential granting access to a Security Identification Display Area may be screened at any time while gaining access to, working in, or leaving a Security Identification Display Area.”


As a condition of being an airport badge-holder, you acknowledge and accept the security responsibilities when working in the SIDA, Sterile, or Secured Areas of the airport and understand your security obligations.

PAGE 6 of 8 APPLICANT INITIAL: __________ DATE: ______

APPLICANT NAME:

BADGE TYPE:


Within the past ten years, have you been convicted of or found not guilty by reason of insanity involving any of the following offenses? A ‘yes’ answer for any of the disqualifying crimes will be reason to deny the issuance of the identification media.
ITEM	YES	NO	ITEM	YES	NO
Aircraft piracy			Felony involving importation or manufacture of a controlled substance
Aircraft piracy outside the special aircraft jurisdiction of the United States			Felony involving the illegal possession of a controlled substance punishable by a maximum term of imprisonment of more than 1 year
Armed or felony unarmed robbery			Felony involving possession or distribution of stolen property
Assault with intent to murder			Felony involving theft
Carrying a weapon or explosive aboard an aircraft			Felony involving violence at International Airports
Commission of certain crimes aboard aircraft in flight			Felony involving willful destruction of property
Conspiracy or attempt to commit any of the criminal acts listed on this application			Forgery of certificates, false marking of aircraft, and other aircraft registration violations
Conveying false information and threats			Improper transportation of a hazardous material
Destruction of an aircraft or aircraft facility			Interference with air navigation
Distribution of or intent to distribute a controlled substance			Interference with flight crew members or flight attendants
Espionage			Kidnapping or hostage taking
Extortion			Lighting violations involving transporting controlled substances
Felony arson			Murder
Felony involving a threat			Rape or aggravated sexual abuse
Felony involving aggravated assault			Sedition
Felony involving bribery			Treason
Felony involving burglary			Unlawful entry into an aircraft or airport area that serves air carriers or foreign air carriers contrary to established security requirements
Felony involving dishonesty, fraud, or misrepresentation			Unlawful possession, use, sale, distribution or manufacture of an explosive or weapon

PAGE 7 of 8 APPLICANT INITIAL: __________ DATE:

APPLICANT NAME:

BADGE TYPE:

I understand that if I am convicted of any of the above disqualifying crimes after I receive a Phoenix Sky Harbor International Airport Photo ID that I must report this conviction and surrender the ID badge within 24 hours to:

City of Phoenix Aviation Department
Operations Center – Security Badging Office
3300 Sky Harbor Boulevard
Phoenix, AZ 85034
1-602-273-2036


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).

SIGNATURE

DATE:

PAGE 8 of 8 APPLICANT INITIAL: __________ DATE: ______