DFW Airport Identification/Access Badge Application
Page 1 of 9
To be completed by Applicant
Last Name: |
First Name: |
Middle Name: |
You must provide your full legal name (last, first and middle name) at the top of every page of the application.
Social Security No.: |
- |
- |
Date of Birth: |
/ |
/ |
|
|
|
|
|
Name of Employer: |
|
|
Dept./Branch (if applicable): |
|
|
|
|
|
|
|
Applicant for 2nd badge with 2nd employer
Replacement badge applicant (replace lost or stolen badge)
Do you hold another DFW Airport Identification/Access Badge with another employer who is not listed above?
If Yes, you are required to provide the name of your other employer.
You are required to provide any other names you used previously (Alias). If you have used other names previously, you must provide the first name, last name and if applicable, the middle name for each Alias you used. Please note that a nickname is not considered an Alias and is not to be included on this form. If you have not used any other names, please leave the fields blank.
Alias 1 Last Name |
, |
First Name |
Middle Name |
Alias 2 Last Name |
, |
First Name |
Middle Name |
Alias 3 Last Name |
, |
First Name |
Middle Name |
|
|
|
|
Gender: |
Race: |
Eye Color: |
Hair Color: |
Height: |
ft. |
in. |
Weight: |
lbs. |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Job Title: |
|
|
Company Employee Number: |
|
|
|
|
|
|
|
|
|
|
|
Driver’s License/State ID Number: |
|
State: |
Expiration Date: |
/ |
/ |
|
|
|
|
|
|
|
You are required to provide a current mailing address. |
|
|
|
|
|
Current Mailing Address: |
|
|
Apartment/Suite Number: |
|
|
|
|
|
|
|
|
|
|
|
|
City: |
|
|
State: |
Zip Code: |
|
- |
|
|
You are required to provide a current street address and to bring a document containing your name and the address provided.
Current Street Address: |
|
|
|
Apartment/Suite Number: |
City: |
|
|
State: |
|
Zip Code: |
|
- |
|
|
|
|
You are required to provide a telephone number where you can be reached during the day. |
|
Daytime Phone: |
( |
) |
- |
|
|
|
|
|
|
|
|
|
|
|
Business Phone: ( |
) |
- |
Home Phone: |
( |
) |
- |
|
|
|
|
|
|
|
|
Cell Phone: |
( |
) |
- |
|
|
|
|
|
|
|
|
|
Personal Email Address: |
|
|
Business Email Address: |
|
You are required to provide your country of birth. If you were born in the US or Mexico, you must also provide your State of Birth in addition to your Country of Birth.
Country of Birth: |
State of Birth: |
|
|
You are required to provide your country of citizenship.
Country of Citizenship:
DPS ACO-1 (05/12)
DFW Airport Identification/Access Badge Application
Page 2 of 9
To be completed by Applicant
Last Name: |
|
|
First Name: |
Middle Name: |
|
|
|
|
|
|
Social Security No.: |
- |
- |
Date of Birth: |
/ |
/ |
|
|
|
|
|
Name of Employer: |
|
|
Dept./Branch (if applicable): |
|
|
|
|
|
|
|
Are you a Law Enforcement |
Officer (LEO) or a Federal employee who is either a Naturalized US Citizen or a US Citizen who was |
born abroad? |
Yes |
No |
If yes, the ACO will submit an Alien Registration Number (ARN) of A”100000000” to the TSA. If No, you must provide the information below that is applicable to you.
If you are a US Citizen who was born in the United States and have a US Passport, please provide:
US Passport Number: |
|
|
Expiration: |
/ |
/ |
If you are not a US Citizen, you must provide at least one of the following: |
|
|
|
Alien Registration Number: |
A |
(9 digits, no dashes) |
Expiration: |
/ |
/ |
I-94 Arrival/Departure Record Number: |
(11 digits, no dashes) Expiration: |
/ |
/ |
Do you hold a Non-Immigrant VISA from a foreign country?
If Yes, you are required to provide the VISA control number, which appears in the top right-hand corner of the VISA and is labeled “Control Number.”
Non-Immigrant Visa Control Number: |
Expiration: |
/ |
/ |
If you are a US Citizen who was born abroad or if you are a Naturalized US Citizen, you are required to provide at least one of the following:
US Passport Number: |
Expiration: |
/ |
/ |
|
|
|
|
|
Certificate of Naturalization Number (Form N-550 or N-570): |
|
|
|
|
|
|
|
|
Certificate of US Citizenship Number (Form N-560 or N-561): |
|
|
|
|
|
Certification of Report of Birth (Form DS-1350): |
|
(A 10 digit number beginning with “159-” that appears in the |
top right-hand corner of the document. If your DS-1350 was issued prior to 1990 and does not contain a document control number, you must enter “DS-1350” in the field above and you must bring the document with you to the ACO.)
Consular Report of Birth Abroad (Form FS-240):(A 10 digit number beginning with “159-“ that appears in
the top right-hand corner of the document. If your FS-240 was issued prior to 1990 and does not contain a document control number, you must enter “FS-240” in the field above and you must bring the document with you to the ACO.)
Certification of Birth Abroad (Form FS-545):(A document that was issued prior to 1990 and does not
contain a document control number. You must enter “FS-545” in the field above and you must bring the document with you to the ACO.)
DPS ACO-1 (05/12)
DFW Airport Identification/Access Badge Application
Page 3 of 9
To be completed by Applicant
Last Name: |
|
|
First Name: |
Middle Name: |
|
|
|
|
|
|
Social Security No.: |
- |
- |
Date of Birth: |
/ |
/ |
|
|
|
|
|
Name of Employer: |
|
|
Dept./Branch (if applicable): |
|
|
|
|
|
|
|
Disqualifying Criminal Offenses
Individuals seeking unescorted access authority and/or performing security screening are required to undergo a fingerprint-based criminal history records check that does not disclose that he/she has a disqualifying criminal offense. There are twenty-eight (28) disqualifying crimes under Chapter 49 of the Code of Federal Regulations (Part 1542-209) that will disqualify you from receiving a DFW identification/access badge. Those crimes are:
1.Forgery of certifications, false marking of aircraft, and other aircraft registration violation;
2.Interference with air navigation;
3.Improper transportation of a hazardous material;
4.Aircraft piracy;
5.Interference with flight crew members or flight attendants;
6.Commission of certain crimes aboard aircraft;
7.Carrying a weapon or explosive aboard aircraft;
8.Conveying false information and threats;
9.Aircraft piracy outside the special aircraft jurisdiction of the United States;
10.Lighting violations involving transporting controlled substance;
11.Unlawful entry into an aircraft or airport area that serves air carriers;
12.Destruction of an aircraft facility;
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:
a.Willful destruction of property;
b.Importation or manufacture of a controlled substance;
c.Burglary;
d.Theft;
e.Dishonesty, fraud, or misrepresentation;
f.Possession or distribution of stolen property;
g.Aggravated assault;
h.Bribery; or
i.Illegal possession of a controlled substance punishable by a maximum term of imprisonment of more than one (1) year;
27.Violence at international airports; or
28.Conspiracy or attempt to commit any of the criminal acts listed in this paragraph.
A copy of the criminal record received from the FBI will be provided to the individual, if requested by the individual in writing. The request should be submitted to the Airport Security Coordinator, who is the point of contact for questions about the results of a criminal history records check (CHRC).
Privacy Act Notice
Authority: The authority for collecting this information is 49 U.S.C. 114, “Transportation Security Administration,” and 49 U.S.C. 44936, “Employment Investigations and Restrictions.”
Purpose: This information is needed to verify your identity and to retrieve your criminal history record to evaluate your suitability for access to airport sterile areas and security identification display areas (SIDA), and aircraft. Your Social Security Number (SSN) will be used as your identification number in this process and to verify your identity. Furnishing this information, including your SSN, is voluntary, however, failure to provide it will prevent the completion of your criminal history records check, without which you may not be granted aircraft, sterile area or SIDA access.
Routine Uses: Routine uses of this information include disclosure to the U.S. Office of Personnel Management for processing and data verification, to the FBI to retrieve your criminal history record, to TSA contractors or other agents who assist in the maintenance and operation of the fingerprint system, to airport operators or aircraft operators to evaluate suitability for aircraft, sterile area or SIDA access, to appropriate governmental agencies for law enforcement or security purposes, or in the interests of national security, and to foreign and international governmental authorities in accordance with law and international agreement.
I have read the preceding information and understand my rights as an applicant. By signing this application I acknowledge my understanding and agree to all the terms in this Privacy Act Notice.
DPS ACO-1 (05/12)
DFW Airport Identification/Access Badge Application
Page 4 of 9
To be completed by Applicant
Last Name: |
|
|
First Name: |
Middle Name: |
|
|
|
|
|
|
Social Security No.: |
- |
- |
Date of Birth: |
/ |
/ |
|
|
|
|
|
Name of Employer: |
|
|
Dept./Branch (if applicable): |
|
|
|
|
|
|
|
Security Training Notice
•Applicants for Security Identification Display Area (SIDA) badges are required to take the DFW SIDA Training and the Ramp Safety training after they have met the Criminal History Records Check (CHRC) and Security Threat Assessment (STA) requirements.
•Applicants must pass the DFW SIDA Training and Ramp Safety training final assessments with a score of 100% on each training course before a SIDA badge will be issued.
•Applicants will be given a DFW SIDA Training Pocket Guide and Ramp Safety Pocket Guide as study material when they are fingerprinted in the ACO.
•The DFW SIDA Training Pocket Guide is available in English and Spanish for study purposes only.
•Applicants may not use the DFW SIDA Training Pocket Guide or the Ramp Safety Pocket Guide while taking the training courses or during the final assessments.
•Applicants may not receive assistance of any kind during the training courses or during the final assessments except for assistance in the use of the computer equipment.
•Applicants may take the DFW SIDA Training and the Ramp Safety training on three (3) separate occasions within the thirty (30) days following the CHRC or STA approval date, whichever is the later date.
•Applicants that do not pass the DFW SIDA Training and the Ramp Safety Training by the third (3rd) attempt will be required to start the badging process from the beginning, including fingerprinting.
•Applicants’ employers are expected to train applicants prior to sending applicants back to the ACO to begin the badging process again.
Employee Portal Rules Notice
•The Employee Portals are monitored by video camera at all times.
•Employee Portals may only be used by SIDA badge holders who have been authorized to use the portals.
•No public access through the Employee Portals.
•Use of the Employee Portals for the purpose of boarding an aircraft for travel is prohibited, except for on-duty air carrier flight crew who are in uniform.
•Escorting and/or piggy-backing is prohibited.
•Employees are subject to random inspections of their person and property.
•Items prohibited at TSA checkpoints are also prohibited at Employee Portals, except for liquids, gels, and/or aerosols. O Tools prohibited at the TSA checkpoints cannot be taken through an Employee Portal.
O Items to be sold to the traveling public may not be taken through an Employee Portal.
•Failure to abide by the Employee Portal rules may subject the badge holder to suspension or revocation of their badge and/or access privileges, repeat SIDA security training, civil or criminal prosecution, and/or fines imposed by the TSA for violating TSA Federal regulations.
Privacy Act Notice
Authority: 49 U.S.C. §§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 and will forward any fingerprint information to the Federal Bureau of Investigation to conduct a criminal history records check of individuals who are applying for, or who hold, an airport-issued identification media or who are applying to become a Trusted Agent of the airport operator. 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 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 Transportation Security Threat Assessment System (T-STAS), DHS/TSA 002.
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.
DPS ACO-1 (05/12)
DFW Airport Identification/Access Badge Application
Page 5 of 9
To be completed by Applicant
Last Name: |
|
|
First Name: |
Middle Name: |
|
|
|
|
|
|
Social Security No.: |
- |
- |
Date of Birth: |
/ |
/ |
|
|
|
|
|
Name of Employer: |
|
|
Dept./Branch (if applicable): |
|
|
|
|
|
|
|
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 at http://uscode.house.gov/search/criteria.shtml).
By my signature below, I certify that I do not have a disqualifying criminal offense and I do consent to an electronic fingerprint criminal history records check; in accordance with 49 CFR Part 1542.209. I understand my obligation to disclose to the airport operator within 24 hours if convicted of any disqualifying criminal offense that occurs while having unescorted access authority.
Pursuant to 49 CFR Parts 1542 and 1544, the Airport Board has implemented an electronic fingerprinting Criminal History Records Check (CHRC), which includes this application process and issuance of access badges for individuals whose work requires access to secured areas of DFW Airport. Information provided on this application, including individual social security numbers, will be used by the Airport Board and the Department of Homeland Security Transportation Security Administration (TSA) in accordance with applicable laws to enable the Airport Board and TSA to implement these Federal requirements and the fingerprint CHRC results may also be shared with CBP officials in order to authorize access to areas of DFW Airport controlled by CBP. Social Security Numbers may be used for identification of applicants, sorting and tracking of badges, verification of information and identity and, in the event of misuse of any badge or other privilege connected with this application, for law enforcement or security purposes. Disclosure of an applicant’s social security number is mandatory and failure to do so will result in denial of badging privileges.
By my signature below, I certify that I have read the Security Training Notice and the Employee Portal Rules Notice and acknowledge my understanding and agreement to abide by all the terms and conditions set forth in the Security Training Notice and the Employee Portal Rules Notice.
By my signature below, I certify that I understand it is the policy of DFW Airport’s Department of Public Safety, to Suspend or Revoke access privileges for violation of Federal, State, or Local Laws or the Airport’s Security Program. I also understand that a badge holder’s access may be suspended while they are a party of interest or a suspect in an active criminal investigation or are currently charged with a Felony, Class A or Class B Misdemeanor criminal charge.
Social Security Administration Certification
I authorize the Social Security Administration to release my Social Security Number (SSN) and full name to the Transportation Security Administration, Office of Transportation Threat Assessment and Credentialing (TTAC), Attention: Aviation Programs (TSA-19)/Aviation Worker Program, 601 South 12th Street, Arlington, Virginia 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 Social Security records, I could be punished by a fine or imprisonment or both.
By my signature below, I certify that I have read the Social Security Administration Certification and acknowledge my understanding and consent to Social Security Administration releasing my information to verify that my SSN is correct.
Please print the full legal name of the applicant below.
First Name |
|
Middle Name |
Last Name |
|
/ |
/ |
- |
- |
|
|
|
|
Applicant’s Date of Birth |
Applicant’s Social Security Number |
|
|
|
|
/ |
/ |
|
|
|
Applicant’s Signature |
|
Date of Applicant’s Signature |
DPS ACO-1 (05/12)
DFW Airport Identification/Access Badge Application
Page 6 of 9
To be completed by Employer
Applicant Last Name: |
|
|
|
|
First Name: |
|
|
Middle Name: |
|
|
|
|
|
|
|
|
Applicant Social Security No.: |
- |
- |
|
|
Date of Birth: |
/ |
/ |
|
|
|
|
|
|
|
|
|
|
Name of Employer: |
|
|
|
|
|
|
Dept./Branch (if applicable): |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Name of Employer: |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Employer’s Current Mailing Address: |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
City: |
|
|
State: |
|
|
|
Zip Code: |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Employer’s Current Street Address: |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
City: |
|
|
State: |
|
|
|
Zip Code: |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Business Phone: |
( |
) |
- |
|
Fax: |
( |
) |
- |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Web-Site Address: |
|
|
|
|
|
|
|
|
|
|
By my signature below, I certify that I understand it is the policy of DFW Airport’s Department of Public Safety, to Suspend or Revoke access privileges for violation of Federal, State, or Local Laws or the Airport’s Security Program. I also understand that a badge holder’s access may be suspended while they are a party of interest or a suspect in an active criminal investigation or are currently charged with a Felony, Class A or Class B Misdemeanor criminal charge.
Pursuant to 49 CFR Parts 1542 and 1544, the Airport Board has implemented an electronic fingerprinting Criminal History Records Check (CHRC), which includes this application process and issuance of access badges for individuals whose work requires access to secured areas of DFW Airport. Information provided on this application, including individual social security numbers, will be used by the Airport Board and the Department of Homeland Security Transportation Security Administration (TSA) in accordance with applicable laws to enable the Airport Board and TSA to implement these Federal requirements and the fingerprint CHRC results may also be shared with CBP officials in order to authorize access to areas of DFW Airport controlled by CBP. Social Security numbers may be used for identification of applicants, sorting and tracking of badges, verification of information and identity and, in the event of misuse of any badge or other privilege connected with this application, for law enforcement or security purposes. Disclosure of an applicant’s social security number is mandatory and failure to do so will result in denial of badging privileges.
By my signature below, I certify: that I am a duly authorized representative of the above named employer and as such may execute (sign) this application; that the foregoing information is true, accurate and all information is verified; that the above named employer authorized an electronic fingerprint be obtained for the purpose of performing a criminal history record check; and is responsible for all applicable fees and charges; and that the employee’s Airport Access Badge will be returned upon request, termination, or when access is no longer required; that the above named employee is required to have access to secure areas of the Airport. 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 at http://uscode.house.gov/search/criteria.shtml).
Please print the full legal name of the duly Authorized Employer Representative.
First Name |
|
|
Middle Name or Initial |
|
|
Last Name |
|
|
|
|
|
|
|
|
|
|
/ |
/ |
|
|
|
|
|
|
|
|
Authorized Employer Representative’s Signature |
|
|
|
Date of Authorized Employer Representative’s Signature |
Please print the contact information of the duly Authorized Employer Representative below. |
|
|
|
Email Address: |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Business Phone: |
( |
) |
- |
Fax: |
( |
) |
- |
Cell: |
( |
) |
- |
|
|
|
|
|
|
|
|
|
|
|
|
DPS ACO-1 (05/12)
DFW Airport Identification/Access Badge Application
Page 7 of 9
To be completed by DFW Authorized Badge Sponsor
Applicant Last Name: |
|
|
|
|
|
|
First Name: |
|
|
|
|
|
|
|
Middle Name: |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Applicant Social Security No.: |
- |
- |
|
|
|
|
|
Date of Birth: |
/ |
|
|
|
/ |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Name of Employer: |
|
|
|
|
|
|
|
|
Dept./Branch (if applicable): |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Badge Color |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Yellow SIDA |
|
|
Red SIDA |
|
|
|
|
|
Blue SIDA |
|
Green Non-SIDA |
|
|
|
|
White ID |
|
|
|
Airline Tenant |
|
|
Government |
|
|
|
Airport Board |
Sterile Access Only |
|
|
|
Board Employees/Contractors |
|
Sponsored |
|
|
Sponsored |
|
|
|
Sponsored |
|
|
|
|
|
|
|
|
|
Airport Board Sponsored |
|
Badge Expiration |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
2 Year |
|
1 Year |
|
|
6 Month |
|
|
3 Month |
|
Other Date Less than 1 Year |
/ |
|
|
/ |
|
|
Expiration |
Expiration |
Expiration |
|
Expiration |
Expiration |
|
|
|
|
|
MM/DD/YYYY |
|
|
|
Please note that 2 year expiration can only be authorized for SIDA badges and Airport Board employee White ID badges. |
Access Codes |
Sponsoring Authority must place initials in the next field to the right after the last access code assigned on the |
|
|
|
|
|
row. Application will be voided if initials are not present. |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
If you are a signatory airline who is a participating 49 CFR Part 1544 carrier, please provide the following:
Submitting Official Number (SON) (if applicable) |
|
Unique Identifier - UID (if applicable) |
By my signature below, I certify that I understand it is the policy of DFW Airport’s Department of Public Safety, to Suspend or Revoke access privileges for violation of Federal, State, or Local Laws or the Airport’s Security Program. I also understand that a badge holder’s access may be suspended while they are a party of interest or a suspect in an active criminal investigation or are currently charged with a Felony, Class A or Class B Misdemeanor criminal charge.
Pursuant to 49 CFR Parts 1542 and 1544, the Airport Board has implemented an electronic fingerprinting Criminal History Records Check (CHRC), which includes this application process and issuance of access badges for individuals whose work requires access to secured areas of DFW Airport. Information provided on this application, including individual social security numbers, will be used by the Airport Board and the Department of Homeland Security Transportation Security Administration (TSA) in accordance with applicable laws to enable the Airport Board and TSA to implement these Federal requirements and the fingerprint CHRC results may also be shared with CBP officials in order to authorize access to areas of DFW Airport controlled by CBP. Social Security numbers may be used for identification of applicants, sorting and tracking of badges, verification of information and identity and, in the event of misuse of any badge or other privilege connected with this application, for law enforcement or security purposes. Disclosure of an applicant’s social security number is mandatory and failure to do so will result in denial of badging privileges.
By my signature I certify: that I am authorized to approve this application; that the above named employer is required to have employees with unescorted access to secure and/or sterile areas of the Dallas/Fort Worth International Airport. I have personal knowledge of the employer and the employer’s need to have employees’ access secure and/or sterile areas of the Airport. I authorize the issuance of an Airport Access Badge as indicated: (check one badge color; check expiration date; and add Access Matrix Number(s) if applicable). This application expires within 30 days from the date of my signature. 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 at http://uscode.house.gov/search/criteria.shtml).
Please print the full legal name of the Sponsoring Authority below.
First Name |
|
Middle Name or Initial |
|
|
Last Name |
|
|
|
|
|
|
|
|
|
|
|
|
/ |
/ |
|
|
|
|
|
|
|
|
|
|
Sponsoring Authority’s Signature |
|
|
|
|
|
Date of Sponsoring Authority’s Signature |
Please print the contact information of the Sponsoring Authority below. |
|
|
|
|
|
Business Phone: |
( |
) |
- |
Fax: |
( |
) |
- |
Cell: |
( |
) |
- |
|
|
|
|
|
|
Sponsoring Authority’s Sponsor Code: |
|
|
Sponsoring Authority’s Company Code: |
|
|
DPS ACO-1 (05/12)
DFW Airport Identification/Access Badge Application
Page 8 of 9
For Access Control Office Use Only
Applicant Last Name: |
|
|
First Name: |
|
Middle Name: |
|
|
|
|
|
|
Applicant Social Security No.: |
- |
- |
Date of Birth: |
/ |
/ |
|
|
|
|
|
|
Name of Employer: |
|
|
Dept./Branch (if applicable): |
|
|
|
|
|
|
|
|
Trusted Agent who determined the applicant’s identity, employment authorization and who authorized the issuance of the badge:
Copied proof of identity and employment authorization documents and attached to application
IRMS Receipt Number: |
Receipt Date: |
/ |
/ |
|
1st Issuance |
|
|
|
|
Renew within 30 days from expiration |
Exp. Date of Badge: |
/ |
/ |
Badge Number: |
Renew not within 30 days from expiration Exp. Date of Badge: |
/ |
/ |
Badge Number: |
Replace Lost/Stolen 1st Occurrence |
Replace Lost/Stolen 2nd Occurrence |
Replace Lost/Stolen 3rd Occurrence |
A copy of a Police Report listing the badge as stolen property is attached |
|
|
|
|
Replace Damaged/Destroyed while working (no charge) |
|
Replace Damaged/Destroyed by badge holder (fee collected) |
Replace to change level of access (SIDA to Non-SIDA, Non-SIDA to SIDA, etc.), company name, personal name
Documents Presented from List A:
U.S. Passport or US Passport Card
Permanent Resident Card or Alien Registration Card (Form I-551)
Foreign passport that contains a temporary I-551 stamp
Employment Authorization Document (Form I-766)
Foreign passport with photograph and Form I-94 or Form I-94A
Passport from the Federated States of Micronesia or the Republic of the Marshall Islands with Form I-94 or Form I-94A
Documents Presented from List B (Must also have a document from List C):
Driver’s license or State ID card
ID card with photograph issued by federal, state or local government agencies or entities (ex. unexpired DFW badge)
School ID card with photograph
US Military or Military’s dependent card with photograph
Documents Presented from List C (Must also have a document from List B):
Social Security Card (other than a card stating it is not authorization for employment in the US)
Certification of Birth Abroad issued by the Department of State (Form FS-545)
Certification of Report of Birth issued by the Department of State (Form DS-1350)
Original or certified copy of a birth certificate issued by a US state, county, municipal authority or territory
Native American tribal document
U.S. Citizen ID Card (Form I-197)
ID Card for Use of Resident Citizen in the United States (Form i-179)
Employment authorization document issued by DHS (other than the EAD under List A)
Documents to Validate Current Street Address:
Driver’s license or State ID card
Credit card statement, bill, lease agreement
Other – Please specify
Trusted Agent who captured the applicant’s fingerprints:
SIDA Training Pocket Guide and Ramp Safety Pocket Guide given to applicant
DPS ACO-1 (05/12)
DFW Airport Identification/Access Badge Application
Page 9 of 9
For Access Control Office Use Only
|
Applicant Last Name: |
|
|
First Name: |
|
|
Middle Name: |
|
|
|
|
|
|
|
|
|
|
|
Applicant Social Security No.: |
- |
- |
|
Date of Birth: |
/ |
/ |
|
|
|
|
|
|
|
|
|
|
|
Name of Employer: |
|
|
|
Dept./Branch (if applicable): |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Trusted Agent who verified applicant is ready for badge issuance: |
|
|
|
|
|
Fingerprint Date : |
/ |
/ |
CHRC Case Number: |
|
|
|
|
|
CHRC Cleared |
|
Date of CHRC Clearance: |
/ |
/ |
|
|
|
|
STA Approved |
|
Date of STA Approval: |
/ |
/ |
|
|
|
|
Email notification sent |
|
Date Email Sent to Employer: |
/ |
/ |
|
|
|
Trusted Agent who administered SIDA Training and Ramp Safety Training:
IRMS Receipt Number 1st Day: |
Date of Receipt: |
/ |
/ |
IRMS Receipt Number 2nd Day: |
Date of Receipt: |
/ |
/ |
IRMS Receipt Number 3rd Day: |
Date of Receipt: |
/ |
/ |
Date SIDA Training successfully completed: |
/ |
/ |
|
|
Date Ramp Safety Training completed: |
|
/ |
/ |
|
|
Trusted Agent who issued the badge: |
|
|
|
|
|
IRMS Receipt Number: |
|
|
Receipt Date: |
/ |
/ |
|
|
|
|
|
|
|
Badge Issue Date: |
/ |
/ |
|
|
|
|
|
|
|
|
|
|
|
Badge Expiration Date: |
/ |
|
/ |
|
|
|
|
|
|
|
|
|
|
Badge Color: |
|
|
|
|
|
|
|
|
|
|
|
|
|
Badge Number: |
|
|
|
|
|
|
For ACO Supervisory Use Only
Application Voided
Date Voided: |
/ |
/ |
Reason Voided: |
|
|
|
|
|
Supervisor’s Initials: |
|
|
DPS ACO-1 (05/12)
