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THIS SECTION MUST BE COMPLETED IN FULL BY (City of Lebanon)

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Revised March 2019
.
Lebanon Aiport
5 Airpark Road
West Lebanon, NH 03784
(603) 298-8878
Airport Identification Badge Application
Affiliation Name: _______________________
□ New Applicant □ Renewal
THIS SECTION MUST BE COMPLETED IN FULL BY THE APPLICANT
Last Name:
First Name:
Middle Name:
Date of Birth:
Gender:
List all Aliases:
Home Street Address:
City:
State:
Phone:
Driver’s License #:
State:
Exp:
Social Security #:
Country of Birth:
Pilots Only
Pilots License #
Sponsor Name (if applicable): Sponsor Agency (if applicable:)
Supervisor Signature :
Employee Acknowledgement
Challenge Responsibilities:
As a holder of a LEB Airport Identification Badge, you are required to display your badge above the waist, on the outermost garment, at all times while in the Public
Areas, Sterile Area, Secured Area, SIDA, and AOA. You shall present your airport badge for examination upon request by any other badge holder for the purpose of
enforcing airport challenge procedures. Additionally, you must challenge individuals in access controlled areas of the airport without airport badges to ensure they are
authorized to be on airport property.
Lost Badges:
Please return your badge to Airport Operations when no longer authorized, when transferred, or employment is terminated. If your badge is lost, you must report it to
Airport Manager immediately and have it replaced. Replacement of a lost badge will be at your expense at $25. For repeat lost badges, an increased fee applies. These
fees can be found on a lost badge replacement form.
I, the badge applicant, will comply with all rules and regulations, guidelines, and policies concerning airport security and the use of the LEB Airport Identification
Badge. I acknowledge the above statements regarding challenge responsibilities and lost badges. I further acknowledge that I have received applicable training and a
violation of airport rules and regulations may result in a Notice of Violation (NOV). I understand that I am required to submit to searches of my person and property
while in the Sterile Area, Secured Area, SIDA, and AOA. The airport badge shall be used for official company business only. The use of a badge is permitted only while
working for the company named on the badge and never to be used to bypass the TSA screening checkpoint when flying on a commercial flight unless specifically
exempted by Federal law. I further acknowledge that I am subject to a Criminal Background Investigation prior to issuance or renewal of a badge.
Routine Uses: In addition to those disclosures generally permitted under 5 USC 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 USC 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, 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 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 may 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 may be unable to complete your security threat assessment.
LEB reserves the right to suspend, terminate, or revoke this badge at any time with or without cause. This may include criminal investigations or if the employee
fails to abide by any Airport, FAA, and TSA rules and regulations, and local laws.
Applicant Signature:
Date:
I hereby acknowledge that the person named above is a employee of my company and request an Airport access badge.
Name:
Date:
Security Access Authorized:
_______Blue
_______Red
______Yellow _______Green
Background Date: ____________
Initial Fee Paid: $_____________
Expiration Date: _____________
Badge Number: ______________
___________________
__________________________________________
Airport Authorized Signature
Date
FOR AIRPORT MANAGEMENT USE ONLY
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THIS SECTION MUST BE COMPLETED IN FULL BY (City of Lebanon)

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Completed 3 August 2020

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