Fillable Full Legal Name Section I Applicant Information Ronald (Metropolitan Washington Airports Authority)

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Full Legal Name Section I Applicant Information Ronald (Metropolitan Washington Airports Authority)

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03/10/2021 NOTE: APPLICATION MAY BE PRINTED SINGLE SIDED OR DOUBLE SIDED Page 1 of 4
This Section Must be Typed
NEW
RENEWAL ID Badge Number
_____________________________
Badge Color
:
Red
Green
Blue
Purple
Yellow
Orange
R/W/B
Customs Seal
:
Yes
No Date Approved:_______________
Fingerprint Date: _____________________ (Security Tech________) STA #: _______________________________ (Security Tech________)
Fingerprint Case #: _____________________(Security Tech________) STA Approval Date: ___________________ (Security Tech________)
Fingerprint Approved Date: ______________(Security Tech________)
Certification Official
Yes
No
Metropolitan Washington Airports Authority Airport Identification Badge Application
Ronald Reagan Washington National Washington Dulles
International
Section I – Applicant Information
Full Legal Name
Last: ___________________________ First:_____________________________ Middle: __________________________
Other Names Used (Aliases): _____________________________________________________________________________
Per TSA requirements, you must provide a Social Security Number. Failure to provide it may delay or prevent completion of a Security
Threat Assessment by the Transportation Security Administration. Social Security Number: ___________________________
Current Residency Address
Street: ____________________________________________ City/State/ZIP: _____________________________________
Phone: ________________________ Email (optional) _______________________________________________________
Biographical Data
Height: ______ feet; ______inches Weight: _______ pounds Gender:
Male
Female
U.S. State or Country of Birth: _____________________________ Country of Citizenship: __________________________
Race: ______________________ Hair Color: _______________ Eye Color:____________ Date of Birth:_____________
(MM/DD/YYYY)
Employer Information
Company: ________________________________________________ Division (if any):___________________________
Job Title: _________________________________________________ Hire Date: _______________
(MM/DD/YYYY)
Section II – Identification and Work Authorization
(1) Every Applicant must present two forms of unexpired identification issued by a government authority and at least one of which must have a photo.
Acceptable forms of identification are those listed in the table below.
(2) For U.S. Citizens, two forms of ID as described in sentence (1) above; if no ID is provided from List A, you must provide one ID from List B and one
ID from List C in the table below.
(3) For U.S. Citizens born abroad or naturalized U.S. Citizens, have at least one of the following: (i) U.S. Passport, (ii) Certification of Naturalization, or (iii)
Certificate of Birth Abroad (Form DS-1350 or Form FS-545).
(4) For Individuals who hold a non-immigrant visa, provide the visa control number.
(5) For Individuals who are not U.S. Citizens, have at least one of the following; (i) Permanent Resident Card or Alien Registration Receipt Card (Form I-
551), (ii) Arrival-Departure Record (Form I-94) when presented with an unexpired foreign passport bearing the same name and containing an
endorsement of the individual’s non-immigrant status.
List A
U.S. Passport or U.S. Passport Card
Permanent Resident Card or Alien
Registration Receipt Card (Form I-551)
Foreign Passport with I-551 Stamp
Foreign Passport and Form I-94 or Form I-94A
Employment Authorization Document with
Photo (Form I-766)
Passport from the FSM or RMI with Form I-94
or Form I-94A indicating nonimmigrant
admission under the Compact of Free
Association Between the United States and the
FSM or RMI
List B
AND
List C
State Driver’s License
State ID Card
School ID with Photo
Voter’s Registration Card
U.S. Military Card or draft card
U.S. Military Dependent’s ID
U.S. Citizen ID Card (Form I-197)
USCG Merchant Mariner Card
Native American Tribal Document
Canadian Driver’s License
Other ________________________
Social Security Card
Original or Certified Copy of Birth Certificate
Dept. of State Certification of Birth (FS-545)
Dept. of State Report of Birth (DS-1350)
Consular Report of Birth form (FS-240)
Native American Tribal Document
U.S. Citizen ID Card (Form I-197)
Resident Citizen ID Card (Form I-179)
Employment authorization issued by DHS
This Section Must be Typed
This Section Must be Typed
Security Tech: _________
03/10/2021 LAST NAME:____________________________ FIRST NAME:_____________________________ Page 2 of 4
Section III – Applicant’s Security Responsibility Agreement
49 CFR Part 1540 holds each individual responsible for their actions as they may pertain to airport security. Following is a summary of those
responsibilities and obligations as contained in the applicable Orders and Instructions applicable to my possession of an Identification Badge:
1. I will not allow anyone else to use my Identification Badge or SIDA/Secure Area/Sterile Area/AOA access key.
2. I will wear my Identification Badge on my outermost garment at all times SIDA/Secure Area/Sterile Area/AOA.
3. I will ensure proper closing and locking of SIDA/Secure Area/Sterile Area/AOA doors and/or vehicle gates.
4. I will immediately report the theft or loss of my Identification Badge or key to Airport Operations.
5. I will challenge and report any individual who is not displaying an Identification Badge in the SIDA/Secure Area/AOA.
6. I will immediately report any security violation I witness to Airport Operations or Airport Police.
7. I will submit to searches of my person, property, bags, and/or vehicle at any time entering, attempting to enter, or present within the
SIDA/Secure Area/Sterile Area/AOA.
8. I understand that if I am convicted or found not guilty by reason of insanity of any of the crimes on the Fingerprint Application in the
future, I must report such a conviction or finding of not guilty by reason of insanity to the Airport Security Coordinator within 24
hours.
9. I will be screened by TSA at a passenger screening checkpoint prior to boarding a flight. If, after I have been screened, I exit the
sterile or secured areas of the airport I must be re-screened at a passenger screening checkpoint. Using my badge to circumvent
screening is a serious violation and will result in revocation of the badge for a minimum of one year.
I certify that I have read, understand, and will comply with the above security procedures as well as the Orders and Instructions applicable to
my possession of an Identification Badge, and been provided the opportunity to have my questions answered. I acknowledge my security
responsibilities under 49 CFR 1540.105(a). I understand that failure to comply with any applicable security procedure may result in revocation
of my Identification Badge or key(s) which means, I will lose access to security-controlled areas of the airport and I may not be escorted. I
understand that committing certain aviation security violations may result in my information being listed in the TSA Centralized Revocation
Database for 5 years from the date the violation occurred.
Applicant’s
Initials:
______
_____
Section IV – Criminal History
Public Law 107-71 (49 USC 44936) and 49 CFR 1542.209 forbids anyone who has been convicted or found not guilty by reason of insanity
within the previous 10 years of the crimes listed on the fingerprint application from being granted unescorted access to the airport’s Security
Identification Display Area (SIDA). The person cannot be given an identification badge. All applicants must submit fingerprints that will be
used to check the criminal history. A copy of your CHRC sent by the FBI may be obtained from the Airport
Security Coordinator by
submitting a written request. If you contest the accuracy of the information you may directly contact the agency that reported the
disqualifying conviction to correct your record.
Air Carrier Criminal History Record Check Certification (For Air Carriers Only)
I certify that a fingerprint-based CHRC has been successfully conducted for this applicant which did not disclose any disqualifying criminal
offenses in accordance with TSR 1544.229 or 1544.230. I certify that a copy of the Privacy Act Notice on Page 4 of this application has
been provided to the applicant. I further certify that a fingerprint-based CHRC has been processed according to the following dates:
___________ Date of Submission of the fingerprint-based CHRC. Fingerprint Case Number: ______________________________
(Must be less than 45 calendar days prior to badge expiration)
___________ Date Results Received and Certified that the applicant does not have a disqualifying criminal offense in accordance with
TSR 1544.229 or 1544.230.
For ID renewals, if the CHRC results have not been received and certified as of the date of application; I certify and attest that I will
provide such certification no later than 45 calendar days from the Date of Submission of the fingerprint-based CHRC.
Rap Back Enrollment: Yes No --> If Yes, Provide Rap Back No. __________________ Date of subscription___________
By checking “YES” I am certifying enrollment of the applicant into the FBI Rap Back Program as managed through the Air
Carrier identified below. If enrolled in the FBI Rap Back Program, I certify and attest that I will provide notification of any
disqualifying criminal offense as listed in TSR 1544.229 or 1544.230 related to the applicant to the Pass and ID Office or
Airport Operations within 24 hours of discovery.
Air Carrier: _______________________ Certification Official Name (Print): ______________________________________
Certification Official Signature: __________________________________________________________________________
Title: ____________________________________________________ Date: _______________________
The Transportation Security Administration requires the Airports Authority to include the following statement on this application and to have each
applicant sign and date the statement in order to be issued an Identification Badge: “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)”
Applicant’s
Signature:
____________________________________________________
Date:
__________________________
Security Tech: _________
03/10/2021 LAST NAME:____________________________ FIRST NAME:_____________________________ Page 3 of 4
Section V – Company Information and Certification
Company/Employer
Street:
City/State/ZIP:
Phone:
Fax: _E-Mail
: ________________________________________________________
I hereby request that the applicant be granted the following access badge type and/or privileges on their Identification Badge
DCA Badge Type Requested
Blue – Unescorted access to the SIDA, Secured
Area, and Sterile Area.
Yellow – Unescorted access to the Sterile and
security controlled areas, except air
carrier operation areas.
Orange – Unescorted access to the Sterile Area
through the passenger-screening
checkpoint only.
R/W/B – Unescorted access to the SIDA, Secured
Area, and Sterile Area for TSA senior
staff members.
IAD Badge Type Requested
Blue - Unescorted access to the AOA, SIDA, Sterile
Area, and Secured Area with Command
Post
Green - Unescorted access to the AOA, SIDA,
Sterile Area, and Secured Area.
Red - Unescorted access to the Sterile Area.
Joint Use DCA and IAD Badge – Restricted availability
Purple - Unescorted access to DCA and IAD’s
AOA, SIDA, Secured Area, Sterile Area
Special Endorsements:
Gate Agent – Required for jet bridge door timed override for enplaning and deplaning operations. Yes No
Escort Authority - Required to escort un-badged individuals inside the security fence line. Yes No
Customs – Required for access into the areas controlled by U. S. Customs and Border Patrol. Yes No
Command Post – A designation restricted to those individuals approved by Airport Operations. Yes No
***Endorsement Justification for Escort / Command Post Request:
Airfield Driving Privileges DCA IAD
Non-Movement Area (Basic driver permit required for all persons driving inside the security fence line) Yes Yes No
Movement Area (Advanced Permit required for all persons requesting access to runways or taxiways) Yes Yes No
I hereby certify and attest that the individual applicant i) has a specific need for unescorted access authority; and ii) acknowledges their
security responsibilities under 49 CFR 1540.105(a).
Certification Official Name (Print):
__________________________________
Title:
_____________________________________
Certification
Official
Signature:
Date:
____________________
Section VI – Training Endorsements
This Applicant has successfully completed the following training:
DCA Security/SIDA (Required for all badge holders) Yes No Date: ___________ By: _________
IAD Security/SIDA (Required for all badge holders) Yes No Date: ___________ By: _________
Certification Official (Required to sign badge applications for company) Yes No Date: ___________ By: _________
Driver Training Completed For: DCA IAD DCA / IAD
Non-Movement Area Yes Yes No Date: _______/_______ By: _________
Training video required for all persons driving inside the
security fence line.
Advanced Movement Area Yes Yes No Date: _______/_______ By: _________
Training class provided by Airport Operations required for
initial training of all persons requesting access to runways or
taxiways.
Movement Area Yes Yes No Date: _______/_______ By: _________
Training video required for Initial and recurrent training of all
persons requesting access to runways or taxiways.
Security Tech:
Security Tech: _________
03/10/2021 Page 4 of 4
METROPOLITAN WASHINGTON AIRPORTS AUTHORITY USE OF INFORMATION
The U.S. Department of Homeland Security (DHS), Transportation Security Administration (TSA) requires the Metropolitan
Washington Airports Authority to collect the information on these application forms (with a few, minor exceptions) for every
person applying for a badge. This application and other records relating to it are kept confidential by the Airport Security
Coordinator at each airport and only used by the Airports Authority and its agents in administering airport security and the access
control system, in particular. The only exception is that the TSA may examine the Airports Authority’s files at any time and the
TSA requires the information to be submitted to it periodically. TSA also requires the Airports Authority to provide the following
notice:
TSA PRIVACY ACT STATEMENT
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.
I authorize the Social Security Administration to release my Social Security Number and full name to the Transportation Security
Administration. Enrollment 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.
Last: ___________________________ First:____________________________ Middle: ________________________
Date of Birth: ___________________________________ SSN:____________________________________
Signature: ______________________________________ Date Signed:____________________________
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Full Legal Name Section I Applicant Information Ronald (Metropolitan Washington Airports Authority)

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