Fillable Transportation Security Administration APPLICATION FOR NEW OR RENEWAL (Department of Homeland Security)

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Transportation Security Administration APPLICATION FOR NEW OR RENEWAL (Department of Homeland Security)

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U.S.A. forms for Department of Homeland Security

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DEPARTMENT OF HOMELAND SECURITY
Transportation Security Administration
APPLICATION FOR NEW OR RENEWAL SECURITY THREAT ASSESSMENT (STA)
All fields are to be completed unless otherwise noted
SECTION I. General Information
Current STA Number (STA Renewals Only)
Current Employer Name
Current Employer Corporate Address City
State Zip Code
Employer Phone Number
IAC Principal Title
(If IAC Principal)
SSN (Optional)
Daytime
Phone
Number
Date of Birth
(MM/DD/YYYY)
TSA Form 419F (12/17) rev. [File: 400.18]
Previous edition of this form are obsolete
OMB control number 1652-0040
Exp. 08/31/2019
Page 1 of 6
US Passport Number or Certificate of Birth Abroad Number (if applicable)
Naturalization Date (if applicable) Naturalization Certificate Number (if applicable)
Current Mailing Address
City State Zip CodeCountry
Current Residential Address
City State Country
Name (As it appears on the document presented - See Instructions)
First Middle Last
Same As Mailing Address
Suffix
Email Address (Optional)
Previous Other Names Used (If Applicable - See Instructions)
First
Middle
Last Suffix
First
Middle
Last Suffix
Place of Birth
City State Country
Country of
Citizenship
Alien Registration Number (if applicable)
Gender
Male Female
IAC Principal (Refer to Page 5 For Definition
Yes No
APPLICATION FOR NEW OR RENEWAL SECURITY THREAT ASSESSMENT (STA)
All fields are to be completed unless otherwise noted
OMB control number 1652-0040
Exp. 08/31/2019
TSA Form 419F (12/17) rev. [File: 400.18]
Previous Residential Address (if applicable, see instructions section)
City State Country Zip Code
Start Date at this Address End Date at this Address
Previous Residential Address (if applicable, see instructions section)
City State Country Zip Code
Start Date at this Address End Date at this Address
Previous Residential Address (if applicable, see instructions section)
City State Country Zip Code
SECTION II. Applicant Acknowledgement
This information I have provided on this application 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, or an omission of a material fact, on this application
can be punished by fine or imprisonment or both (see section 1001 of Title 18 United States Code), and may be grounds for denial
of authorization or in the case of parties regulated under this section, removal of authorization to operate under this chapter, if
applicable. I acknowledge that if I do not successfully complete the Security Threat Assessment (STA), the Transportation
Security Administration (TSA) may notify my employer. If TSA or other law enforcement agency becomes aware that I may pose
an imminent threat to an operator or facility, TSA may provide limited information necessary to reduce the risk of injury or damage
to the operator or facility.
Applicant Signature Date
I have authenticated the identity and work authorization of the individual for whom this STA application is being submitted by
reviewing a Photo Identification issued by a government authority and work authorization documents as required under 49 C.F.R
§ 1540.203(b). I have verified that the individual's written application contains the Privacy Act Notice required under 49 C.F.R.§
1540.203(c)(11), and I acknowledge that I am required to retain the individual's signed STA application, all documents to prove
identity and work authorization, and any communications with TSA regarding the individual's application (either in electronic or
hardcopy format) for 180 days following at the end of the individual's service as required under 49 C.F.R. § 1540.203(d).
SECTION III. Employer Acknowledgement
Employer Signature Date
Previous edition of this form are obsolete
Page 2 of 6
Start Date at this Address End Date at this Address
Start Date at this Address End Date at this Address
City State Country Zip Code
Previous Residential Address (if applicable, see instructions section)
Zip Code Start Date at this Address
End Date at this Address
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APPLICATION FOR NEW OR RENEWAL SECURITY THREAT ASSESSMENT (STA)
All fields are to be completed unless otherwise noted
OMB control number 1652-0040
Exp. 08/31/2019
Who Needs to Complete a Security Threat Assessment: The following sections are contained in the Code of Federal
Regulations.
§1548.15 Access to cargo: Security Threat Assessments for individuals having unescorted access to cargo.
a. Before an indirect air carrier authorizes and before an individual performs a function described in paragraph (b)
of this section:
1. Each individual must successfully complete a security threat assessment or comparable security threat
assessment described in part 1540 subpart C of this chapter; and
2. Each indirect air carrier must complete the requirements in part 1540 subpart C.
b. The security threat assessment required in paragraph (a) of this section applies to the following:
1. Each individual who has unescorted access to cargo and access to information that such cargo will be
transported on a passenger aircraft; or who performs certain functions related to the transportation,
dispatch or security of cargo for transport on a passenger aircraft or all-cargo as specified in the direct
air carrier's security program; from the time:
i. Cargo to be transported on all cargo aircraft operator with a full all-cargo program under §
1544.01 (a) or by a foreign air carrier under § 1546.10(a) or (b) of this chapter, is accepted by
the indirect air carrier, until the indirect air carrier transfers the cargo to an aircraft operator or
foreign air carrier.
2. Each individual the indirect air carrier authorizes to screen cargo or to supervise the screening of
cargo under § 1548.21.
§1548.16 Security Threat Assessment for each proprietor, general partner, officer, director, and certain owners
of the entity.
a. Before an indirect air carrier permits a proprietor, general partner, officer, director, or owner of the entity to
perform those functions:
1. The proprietor, general partner, officer, director, or owner, of the entity must successfully complete a
security threat assessment or comparable security threat assessment described in part 1540 subpart C
of this chapter; and
2. Each indirect air carrier must complete the requirements in 49 CFR part 1540, subpart C.
b. For purpose of this section, owner means:
1. A person who directly or indirectly own, controls, or has power to vote 25 percent or more of any class
of voting securities or other voting interests of an IAC or applicant to be an IAC; or
2. A person who directly or indirectly controls in any manner the election of a majority of the directors (or
individuals exercising similar functions) of an IAC, or applicant to be an IAC.
c. For purposes of this definition of owner:
1. Members of the same family must be considered to be one person:
i. Same family means parents, spouses, children, siblings, uncles, aunts, grandparents,
grandchildren, first cousins, stepchildren, stepsiblings, and parents-in-law, and spouses of any
of the foregoing.
ii. Each member of the same family, who has an ownership interest in an IAC,or an applicant to
be an IAC, must be identified if the family is an owner as a result of aggravating the ownership
of interests of the same family, any voting interest of any family member must be taken into
account.
iii. In determining the ownership of interests of the same family, any voting interest of any family
member must be taken into account.
2. Voting securities or other voting interest means securities or other interests that entitle the holder to
vote for or select directors (or individuals exercising similar functions).
d. Each indirect air carrier, or applicant to be an indirect air carrier, must ensure that each proprietor, general
partner, officer, director, and owner, of the entity has successfully completed a Security Threat Assessment
under part 1540, subpart C, of this chapter not later than a date to be specified by TSA in a future role in the
Federal Register.
TSA Form 419F (12/17) rev. [File: 400.18]
Previous edition of this form are obsolete
Page 3 of 6
OMB control number 1652-0040
Exp. 08/31/2019
APPLICATION FOR NEW OR RENEWAL SECURITY THREAT ASSESSMENT (STA)
All fields are to be completed unless otherwise noted
§1549.111 Security Threat Assessment for personnel of certified cargo screening facilities.
a. Scope. This section applies to the following:
1. Each individual the certified cargo screening facility authorizes to perform cargo screening or supervise cargo
screening.
2. Each individual the certified cargo screening facility authorizes to have unescorted access to cargo at any
time from the time it is screening until the time it is tendered to another certified cargo screening facility, an
indirect air carrier under 49 CFR part 1548 for transport on a passenger aircraft, an aircraft operator under
part 1544, or a foreign air carrier under part 1546.
3. The senior manager or representative of its facility in control of the operations.
4. The security coordinators and their alternates.
b. The security threat assessment required in paragraph (a) of this section applies to the following:
1. Each individual who has unescorted access to cargo and access to information that such cargo will be
transported on a passenger aircraft; or who has unescorted access to cargo that has been screened for
dispatch, or security of cargo for transport on a passenger aircraft or all-cargo aircraft, as specified in the
aircraft operator's security program - from the time:
i. The cargo reaches a location where an aircraft operator with a full all-cargo program consolidates or
inspects it pursuant to security program requirements until the cargo enters an airport Security
Identification Display Area or is transferred to another TSA regulated aircraft operator, foreign air
carrier, or indirect air carrier; or
ii. An aircraft operator with a full program accepts the cargo until the cargo:
o Enters an airport Security Identification Display Area;
o Is removed from the destination airport; or
o Is transferred to another TSA regulated aircraft operator, foreign air carrier, or indirect air
carrier.
2. Each individual the aircraft operator authorizes to screen cargo or to supervise the screening of cargo under §
1544.205.
§1544.228 Access to cargo and cargo screening: Security Threat Assessments for cargo personnel in the United
States.
This section applies in the United States to each aircraft operator operating under a full program under § 1544.101(a) or a full
all-cargo program under § 1544.101(h).
a. Before an aircraft operator authorizes and before an individual performs a functions described in paragraph (b) of this
section:
1. Each individual must successfully complete a security threat assessment or comparable security threat
assessment described in part 1540 subpart C of this chapter; and
2. Each aircraft operator must complete the requirements in part 1540 subpart C.
b. The security threat assessment required in paragraph (a) of this section applies to the following:
1. Each individual who has unescorted access to cargo and access to information that such cargo will
be transported on a passenger aircraft; or who has unescorted access to cargo that has been
screened for security of cargo for transport on a passenger aircraft or all-cargo aircraft, as specified
in the aircraft operator's security program; from the time:
i. The cargo reaches a location where an aircraft operator with a full all-cargo program
consolidates or inspects it pursuant to security program requirements until the cargo enter
an airport Security Identification Display Area or is transferred to another TSA regulated
aircraft operator, foreign air carrier, or indirect air carrier; or
ii. An aircraft operator with a full program accepts the cargo until the cargo:
A. Enters an airport Security Identification Display Area;
B. Is removed from the destination airport; or
C. Is transferred to another TSA regulated aircraft operator, foreign air carrier, or
indirect air carrier.
2. Each individual the aircraft operator authorizes to screen cargo or to supervise the screening of
cargo under §1544.205.
§1546.213 Access to cargo: Security Threat Assessments for cargo personnel in the United States.
This section applies in the United States to each foreign air carrier operating under § 1546.101 (a), (b), or (e)
a. Before a foreign air carrier authorizes and before an individual performs a functions described in paragraph
(b) of this section:
1. Each individual must successfully complete a security threat assessment or comparable security
threat assessment described in part 1540 subpart C of this chapter; and
TSA Form 419F (12/17) rev. [File: 400.18]
Previous edition of this form are obsolete
Page 4 of 6
APPLICATION FOR NEW OR RENEWAL SECURITY THREAT ASSESSMENT (STA)
All fields are to be completed unless otherwise noted
OMB control number 1652-0040
Exp. 08/31/2019
TSA Form 419F (12/17) rev. [File: 400.18]
Previous edition of this form are obsolete
Page 5 of 6
2. Each aircraft operator must complete the requirements in part 1540 part C
b. The security threat assessment required in paragraph (a) of this section applies to the following:
1. Each individual who has unescorted access to cargo and access to cargo that has been screened for
transport on a passenger aircraft or all-cargo aircraft, as specified in the foreign aircraft operator's or
foreign air carrier's security program-from the time:
i. The cargo reaches a location where a foreign air carrier under §1546.101 (e) consolidates or
inspects it pursuant to security program requirements, until the cargo enters an airport
Security Identification Display Area or is transferred to another TSA regulated aircraft
operator, foreign air carrier, or indirect air carrier; or
ii. A foreign air carrier under §§ 1546.101 (a) or (b) accepts the cargo, until the cargo:
o Enters an airport Security Identification Display Area;
o Is removed from the destination airport; or
o Is transferred to another TSA regulated aircraft operator, foreign air carrier, or
indirect air carrier.
2. Each individual the foreign air carrier authorizes to screening cargo or to supervise the screening of
cargo under § 1546.205.
Instructions for Completing Section I.
Country of Citizenship: If the applicant is a U.S. citizen born abroad please provide the 10-digit document number from the
applicant's Certificate of Birth Abroad, Form DS-1350. If the applicant has been naturalized as a US Citizen, please provide your
US passport number or Date of Naturalization and Naturalization Certificate Number. Be sure to designate that you are a US
citizen if you have been naturalized.
Alien Registration Number: Please provide your Alien Registration Number if you are not a US citizen. Please do not enter an
"A" before the Alien Registration Number.
Residential/Physical Address Information: Please provide the last 5 years of residential address information (no PO Boxes).
use the back of the form or attach an additional sheet if you need to submit more than 5 residential addresses.
Social Security Number: Social Security Number is optional but failure to provide it may result in a delay or prevent completion
of Security Threat Assessment.
IAC Principal Division: Anyone who is a proprietor, general partner, officer, director, or owner of the entity. Owner means a
person who directly or indirectly own, controls, or has power to vote 25 percent or more of any class of voting securities or other
voting interests of an IAC or applicant to be an IAC; or a person who directly or indirectly controls in any manner the election of a
majority of the directors (or individuals exercising similar functions) of an IAC, or applicant to be an IAC.
Examples of Previous and Other Names:
Example A:
Name: Melissa Anna Brown
Name on the Government picture ID and Work authorization are the same.
Melissa Ann Brown must be listed as the Applicants Name in the STA Application Name field.
Example B:
Name: Melissa Anna Brown
Government picture ID names Melissa Anna Brown but the Work authorization names Melissa A. Brown.
Melissa Anna Brown must be listed as the Applicants Name in the STA Application Name field AND Melissa A. Brown
must be listed on the STA Application Previous and Other Names field.
Example C:
Name: Melissa A. Brown
Government picture ID names Melissa A. Brown but the Work authorization names Melissa Anna Brown.
Melissa Anna Brown must be listed as the Applicants Name in the STA Application Name field AND Melissa A. Brown
must be listed on the STA Application and Other Names field.
NOTE: If the Applicant has a middle name that does not appear on the ID or work authorization, or if the Applicant is known by
more than one name, each name must be included in the Previous and Other Names data field. If the Applicant uses an initial
as part of his/her name, the initial must be spelled out in the Previous and Other Names data field with the rest of the Applicants
full name.
Previous and Other Names include Alias, Nicknames, Maiden Names.
APPLICATION FOR NEW OR RENEWAL SECURITY THREAT ASSESSMENT (STA)
All fields are to be completed unless otherwise noted
OMB control number 1652-0040
Exp. 08/31/2019
Privacy Act Statement: Authority: The authority for collecting this information is 49 U.S.C. §§ 114 and 44901.
Principal Purpose: This information is needed to verify your identity and to conduct a Security Threat Assessment to evaluate
your suitability for completing the functions required by this position.
Routine Uses: Routine uses of this information include disclosure to TSA contractors or other agents who are providing
services relating to the Security Threat Assessments; to appropriate governmental agencies for law enforcement or security
purposes, or in the interests of national security; to foreign and international governmental authorities in accordance with law
and international agreement; or for this routine uses identified in TSA system of records, DHS/TSA 002 Transportation Security
Threat Assessment System. Disclosure: Failure to furnish your SSN may result in delays in processing your application, but
will not prevent completion of your Security Threat Assessment. Furnishing the other information is mandatory and failure to
provide it may result in you not being granted authorization to have unescorted access to air cargo subject to TSA security
requirements.
Paperwork Reduction Act Burden Statement: TSA is collecting this mandatory collection of information to qualify entities
pursuant to 49 CFR §§ 1548.15, 1548.16, 1549.111, 1544.228, and 1546.213. The public burden for this collection of
information is estimated to be approximately 15 minutes. An agency may not conduct or sponsor, and persons are not required
to, a collection of information unless it displays a valid OMB control number. The control number assigned to this collection is
OMB number 1652-0040, which expires 08/31/2019. Send comments regarding this burden estimate or any other aspect of this
collection of information including suggestions for reducing this burden to TSA PRA Officer, TSA-11, 601 S. 12th Street,
Arlington, VA 20598-6011. ATTN: PRA 1654-0040.
Previous edition of this form are obsolete
TSA Form 419F (12/17) rev. [File: 400.18]
Page 6 of 6
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Transportation Security Administration APPLICATION FOR NEW OR RENEWAL (Department of Homeland Security)

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Completed 14 October 2020

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