Miami Airport Badge Application Form PDF Details

In order to maintain the safety and security that is paramount in Miami airport operations, the Miami-Dade Aviation Department has instituted a comprehensive and stringent application process delineated in the Miami Airport Badge Application form. This document, crucial for anyone seeking unescorted access to secure areas, mandates meticulous completion and adherence to specific guidelines. Applicants must provide detailed personal information, undergo a Criminal History Records Check (CHRC), and conform to Title 49 of the Code of Federal Regulations pertaining to security at airports. The process is designed to rigorously vet individuals through biographic and biometric data checks conducted by the Department of Homeland Security (DHS) and the Federal Bureau of Investigation (FBI), ensuring that only those meeting the highest security standards are granted unescorted access. Additionally, this procedure includes employer certification, verifying the applicant's employment status and compliance with federal regulations. Emphasizing the serious nature of the security measures, the form outlines penalties for non-compliance or falsification of information, including potentially severe legal repercussions. This multilayered approach underscores the commitment of the Miami-Dade Aviation Department to uphold airport safety and secure operations amidst increasing security demands.

QuestionAnswer
Form NameMiami Airport Badge Application Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesmia access control form, mia access form pdf, miami international airport badge, mia access control form pdf

Form Preview Example

SECURITY DIVISION – CREDENTIALING SECTION Terminal D, 3rd floor

Miami-Dade Aviation Department

Post Office Box 025504 AMF, Miami, Florida 33102 (305) 876-7188

AIRPORT IDENTIFICATION BADGE APPLICATION

All areas must be completed upon submission and must be typed. Signatures by the employee and authorized company representatives will only be accepted using blue ink. The Miami-Dade Aviation Department (MDAD) will not accept this form if it is altered (including use of correction fluid), torn, folded, bent or otherwise defaced. The application must be processed within two weeks of the date it is signed by the authorized company representative (s).

Section I-Applicant Information

 

Social Security Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

First Name:

 

Middle Name:

Last name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Birth:

 

Job Title:

 

Height: _____

Hair color: ____

Sex: M F

 

 

(MM/DD/YYYY)

 

 

 

 

Weight: _____

Eye color: ____

Race: _____

 

 

 

 

 

 

 

 

 

 

 

 

Home Address (incl. City/State/Zip):

 

 

 

 

 

Phone Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other Names Used (Including Maiden name and any aliases)

 

 

 

 

FIRST NAME

 

 

MIDDLE NAME

 

 

 

LAST NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(1)Every Applicant must present two forms of unexpired identification bearing the same name 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 paragraph (1) if no ID 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

_

ard _____________Exp._____

-Immigrant Visa and I-94#_________________

-551 Stamp: Country______

#______________________________ Exp. ________

 

 

List B

 

*AND*

 

List C

 

 

ense: State_______

 

 

 

 

 

 

 

# _____________________________

 

 

 

 

 

issued by a State,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

County, Municipal Authority, or US

 

 

 

 

 

 

*OR*

gov’t agencies with photo

 

 

Territory

 

 

 

 

 

 

 

#____________________Exp.______

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Birth (FS-545) _______________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#____________________ Exp._______

 

(DS-1350) __________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Country of Birth:

Country of Citizenship:

CUSTOMS AND BORDER PROTECTION ONLY

CBP Approval Signature: ______________________ (BLUE INK ONLY) Approval Date:

 

/

/

Comments:_____________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

****FOR MDAD ACCESS CONTROL OFFICE USE ONLY****

 

 

 

 

 

SIDA Training Date:

Badge Number:

 

 

Badge Access Level:

 

Date Issued:

 

 

Expiration Date:

 

Applicant’s

 

 

 

 

 

 

 

 

 

 

 

 

 

Initials

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ID Processed By:

 

 

Reason for GU/Reprint:

 

 

 

 

 

 

GU/Reprint approved by:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CREDENTIALING SECTION PAYMENT

 

VETTING APPROVAL

 

 

 

Date: ___________________

Company Code: ________________

MIA CHRC Identifier: _____________________

Payment Type:

CHRC / ID

CHRC

ID

Lost Badge #:_______________

CHRC Processor: _______________________

 

 

 

 

 

Receipt #: ___________________

__________________

_________________

___________________

CHRC Case #: __________________________

 

B

M C A N

B M C A N

B M C A N

B M C A N

CHRC Received Date #: ___________________

REPLACEMENT (N/C) REASON ________________________________________________________________

STA Approved: Yes No Date:__________________

 

 

 

 

 

MIA ACCESS CONTROL FORM

 

 

March 2018 - 1

Page 1 of 4

 

 

 

 

Section II- Applicant’s Criminal History (Must check “Yes” or “No” for each item listed)

Persons seeking unescorted access to the Security Identification Display Areas (SIDA) or Sterile Areas of an airport and individuals performing security checkpoint screening functions at an airport and their supervisors are subject to the requirements of Title 49 of the Code

of Federal Regulations, Parts 1542.209 or 1544.229. These requirements include a Criminal History Records Checks (CHRC). Indicate below, by checking “Yes” or “No” for each item listed, if you have ever pleaded guilty or nolo contendere (“no contest”), had adjudication

withheld, been convicted or found not guilty by reason of insanity to any of the following:

 

Yes

 

No

 

Forgery of certificates, false marking of aircraft, and other aircraft

 

 

Yes

 

 

 

No

 

 

 

Aircraft piracy

 

 

 

 

 

 

registration violations

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

Interference with air navigation

 

 

Yes

 

 

 

No

 

 

 

Murder

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

Improper transportation of a hazardous material

 

 

Yes

 

 

 

No

 

 

 

Assault with intent to murder

 

 

Yes

 

No

 

Felony involving violence at International Airports

 

 

Yes

 

 

 

No

 

 

 

Espionage

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

Interference with flight crew members or flight attendants

 

 

Yes

 

 

 

No

 

 

 

Sedition

 

 

Yes

 

No

 

Commission of certain crimes aboard aircraft in flight

 

 

Yes

 

 

 

No

 

 

 

Kidnapping or hostage taking

 

 

Yes

 

No

 

Carrying a weapon or explosive aboard an aircraft

 

 

Yes

 

 

 

 

No

 

 

 

Treason

 

 

Yes

 

No

 

Conveying false information and threats

 

 

Yes

 

 

No

 

 

Rape or aggravated sexual abuse

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

Unlawful possession, use, sale, distribution or manufacture of an

 

 

Yes

 

 

 

No

 

 

 

Extortion

 

 

 

 

 

 

explosive or weapon

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

Lighting violations involving transporting controlled substances

 

 

Yes

 

 

 

No

 

 

 

Felony arson

 

 

Yes

 

No

 

Unlawful entry into an aircraft or airport area that serves air

 

 

Yes

 

 

 

No

 

 

 

Distribution of or intent to distribute a

 

 

 

 

 

 

carriers or foreign air carriers contrary to established security

 

 

 

 

 

 

 

 

 

 

 

 

 

controlled substance

 

 

 

 

 

 

requirements

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

Destruction of an aircraft or aircraft facility

 

 

Yes

 

 

 

No

 

 

 

Armed or felony unarmed robbery

 

 

Yes

 

No

 

Aircraft piracy outside the special aircraft jurisdiction of the United

 

 

Yes

 

 

 

No

 

 

 

Felony involving dishonesty, fraud, or

 

 

 

 

 

 

States

 

 

 

 

 

 

 

 

 

 

 

 

 

misrepresentation

 

 

Yes

 

No

 

Felony involving possession or distribution of stolen property

 

 

Yes

 

 

 

 

No

 

 

 

Felony involving a threat

 

 

Yes

 

No

 

Felony involving willful destruction of property

 

 

Yes

 

 

 

No

 

 

 

Felony involving aggravated assault

 

 

Yes

 

No

 

Felony involving importation or manufacture of a controlled

 

 

Yes

 

 

No

 

 

Felony involving bribery

 

 

 

 

 

 

substance

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

Felony involving burglary

 

 

Yes

 

 

 

No

 

 

 

Felony involving theft

 

 

Yes

 

No

 

Felony involving the illegal possession of a controlled substance

 

 

Yes

 

 

 

No

 

 

 

Conspiracy or attempt to commit any

 

 

 

 

 

 

punishable by a maximum term of imprisonment of more than 1

 

 

 

 

 

 

 

 

 

 

 

 

 

of the criminal acts listed on this

 

 

 

 

 

 

year

 

 

 

 

 

 

 

 

 

 

 

 

 

TABLE

 

The MDAD Airport Security Coordinator keeps confidential the criminal history record obtained from the FBI and uses it only for determining whether to issue an Airport Identification Badge (ID Badge). You may get a copy of your criminal history record sent by the FBI to the Airport Security Coordinator by submitting a written request within 30 days after being advised that your criminal history shows you are disqualified from being issued an ID Badge. If you believe that any information is inaccurate, you may directly contact the agency that reported the disqualifying conviction to correct your record.

I understand that I have a continuing obligation under Title 49, CFR, Parts 1542.209 or 1544.229 to disclose to the airport operator within 24 hours if I plead guilty or nolo contendere (“no contest”) to, have an adjudication withheld, been convicted or found not guilty by reason of insanity to any of the disqualifying

crimes listed on this application or the federal security regulations.

Privacy Act Notice: 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 110-52, August 3, 2007); and Executive Order 9397, as amended.

Purpose: The Department of Homeland Security (DHS) will use the biographic information to conduct a security threat assessment. 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 the US-VISIT 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 records to ensure the validity of the information.

Routine Uses: In addition to those disclosures generally permitted under 5 U.S.C. 522a(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. 522a(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 for the NGI system and FBI’s Blanket Routine Uses.

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 a security threat assessment. MDAD has advised me of the purpose, disclosure and uses for submitting my personal information to the Credentialing Section when requesting MDAD issued ID badge media as per Transportation Security Administration (TSA) Security Directive 1542-04-08 series.

MIA ACCESS CONTROL FORM

March 2018 - 1

Page 2 of 4

Section III-Applicant’s Certification

I hereby submit to MDAD Identification Section (Credentialing Section) this application for an ID Badge and agree to the following:

1.To comply at all times with the security rules and policies of MDAD, including the provisions of Chapter 25 and the Transportation Security Administration (TSA), an agency of the United States, including the provisions of Title 49, CFR, Parts 1540,1542, and 1544.

2.All ID Badges remain the property of MDAD; My ID Badge cannot be transferred to another individual or used for any purpose by

another individual; I will visibly display my ID Badge outside my garments on my upper body whenever I am in any area of the airport; I will not aid nor participate in “piggy-backing” (allowing unauthorized access to secure or restricted areas) nor will I otherwise breach, disobey or disregard any security directive, plan or program at the airport; I will challenge any person who enters a secured/restricted area if the person does not properly display an ID Badge. If the person I challenge cannot produce a valid ID Badge, I will immediately notify the Miami-Dade Police Department or the MDAD at (305) 876-0385.

3.Use of the ID Badge constitutes consent to search and monitoring at any area of the airport.

4.MDAD reserves the right to revoke authorization for an ID Badge where such action is determined to be in the best interest of airport security. You must immediately return the ID Badge to MDAD Credentialing Section or your employer upon notification that your authorization has been revoked; I will immediately notify my Supervisor or MDAD of any unattended bags and or suspicious activity; I will immediately notify my employer if my ID Badge is lost or stolen. A non-refundable fee of $75.00 will be assessed for the first replacement and $100.00 for the second replacement within 24 months of original issuance. There will not be a replacement issued for a third time within 24 months of original issuance. The Security Credentialing Section will collect the fee before a replacement ID Badge is issued. Furthermore, a replacement ID Badge may only be issued if I declare in writing that the ID Badge has been lost, stolen, or destroyed. The ID Badge is the property of MDAD. You must immediately return your ID

Badge to your employer or the MDAD Credentialing Section at the end of employment or upon receiving notification that your MDAD ID Badge is being revoked. The MDAD ID Office will issue a receipt as proof of ID Badge return. Failure to comply within 24 hours is in direct violation of the Airport Security Program ASP and you can be subject to a potential $10,000 Civil Penalty Fine assessed by the Transportation Security Administration TSA under title 49 of the Code of Federal Regulations CFR Part 1540.105; 49 USC 46301.

5.In the event of any change in my employee status (i.e. transfer, job title), I will obtain a new ID Badge noting the change and return the original ID Badge.

6.I will immediately notify MDAD and/or my Supervisor if I am arrested of any of the crimes listed under Title 49, CFR, Parts 1542.209 or 1544.229.

7.Contractor Identification Badges are valid only within the construction site to which I am assigned by my employer, within those areas authorized by MDAD and only until the contract is closed out and/or terminated, suspended.

I understand and agree to comply with the terms and conditions provided for in this application and agree to comply with any changes or amendments to the terms and conditions that may be imposed by MDAD. The information that 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 on this application can be punished by fine or imprisonment or both. (See Section 1001, of Title 18 United States Code); (See also Title 49 of the Code of Federal Regulations, Sections 1540.103 and 1542.209)

I authorize the Social Security Administration to release my Social Security Number and full name to the Transportation Security Administration (TSA), Office of Intelligence and Analysis (OIA), Attention: Aviation Programs (TSA-10) Aviation Worker Program, 601 South 12th Street, Arlington, VA 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, imprisonment, or both.

Applicant’s Name ______________________________ Social Security ___________________ Date of Birth ______________

Applicant’s Signature ____________________________________________Date_______________________

(SIGN IN BLUE INK ONLY)

MIA ACCESS CONTROL FORM

March 2018 - 1

Page 3 of 4

Section IV – Access Requirements (to be completed by the employer)

Check all of the following that apply:

____ New Applicant ____ Renewal/Replacement ____ Lost Badge ____ Damaged Badge ____ Federal & Local Law Enforcement

Badge Type

Check the one that applies:

____

Green & Brown

____

Green

____

White with Concourse Access

____

Blue

(Ramp & Cargo Access)

(Ramp

Access only)

(Sterile

Concourse Access)

(MDAD Employee)

____ White

(Terminal Public Access)

____

Brown & Green

____

Brown

____

Lime & Orange

(Cargo & Ramp Access)

(Cargo Access only)

(Cargo

Warehouse only)

____ Yellow

(Contractor)

____ White & Blue

(AOA Delivery Escort Required)

Special Certifications:

____

 

CBP Seal

____

Extended Ajar

(CBP Approval Required)

(Letter Required)

____

Escort Authority

 

____

LEO

(Letter Required)

(Letter Required)

Section V - Employer’s Certification

I certify that this applicant is a direct employee of the company I represent and all information provided by or on behalf of the Employer is true, accurate, and complete. I certify that: (1) I have verified the applicant’s identity by reviewing at least two forms of identification (one of which bears the applicant’s photograph); (2) the applicant has presented to the representative signed below that he or she ha s not been

convicted of a crime identified in 49 CFR 1542.209 or 1544.229; (3) The Employer will immediately report to MDAD Credentialing Section any information that becomes available to us indicating that the applicant was arrested, indicted or convicted of one of the crimes identified

in 49 CFR 1542.209 or 1544.229; (4) The ID Badge is the property of MDAD. The employer will immediately notify and return the employee’s ID Badge to the MDAD Credentialing Section if the employee’s employment is terminated, contract work at the Airport is completed or the employee’s ID Badge is being revoked. Failure to notify MDAD within 24 hours, collect and return the employee’s ID Badge to the MDAD Credentialing Section can subject the employer to a Civil Penalty of up to $10,000, assessed by

the Transportation Security Administration TSA in accordance with title 49 of the United States Code Service 49 USC 46301 (a) (6);

(5)The Employer will immediately notify MDAD Credentialing Section if the applicant’s ID Badge is reported as being lost or stolen and; (6) I certify that the Employer has complied with, and will continue to comply with the provisions of Title 49, CFR, Parts 1540, 1542, and 1544. I also certify that the Employer will inform MDAD Credentialing Section if either of the following applies:

(i)the applicant was unable to support statements made on the application form;

(ii)there are significant inconsistencies in the information provided on the application; or

(iii)information has become available to us indicating a possible conviction of the crime(s) listed in 49 CFR 1542. 209 or 1544.229

I have read and understand the potential penalties described in this application for providing false or misleading information or failing to report as required.

Company Name: ________________________________________

Company Code: ________________________

Mailing Address: ________________________________________________________________________________

Telephone Number: (________)______________________ Email Address: _________________________________

Authorized Representative: _______________________________________

Title: __________________________

(Print Name)

 

 

Authorized Representative’s Signature: _____________________________

Date: __________________________

(SIGN IN BLUE INK ONLY)

 

(APPLICATION EXPIRES 2 WEEKS FROM THIS DATE)

NOTE: SIGNATURE MUST BE ORIGINAL IN BLUE INK. NO COPIES/STAMPS WILL BE ACCEPTED.

MIA ACCESS CONTROL FORM

March 2018 - 1

Page 4 of 4

 

How to Edit Miami Airport Badge Application Form Online for Free

airport identification badge can be filled in without any problem. Just make use of FormsPal PDF tool to do the job right away. The editor is continually updated by us, receiving new awesome functions and turning out to be much more versatile. Getting underway is simple! Everything you should do is stick to the following simple steps directly below:

Step 1: Access the PDF file in our editor by hitting the "Get Form Button" in the top area of this webpage.

Step 2: When you open the tool, you will notice the document all set to be filled in. In addition to filling out different blanks, you can also do other things with the Document, including adding custom text, changing the initial textual content, adding illustrations or photos, affixing your signature to the form, and much more.

This form requires specific information to be filled in, hence be certain to take whatever time to type in what's required:

1. First of all, when filling in the airport identification badge, beging with the page that includes the following fields:

airport badge application writing process described (portion 1)

2. The subsequent part is to complete the next few fields: ard Exp, Immigrant Visa and I, Stamp Country, Exp, govt agencies with photo Exp, Exp, County Municipal Authority or US, Birth FS, Country of Birth, Country of Citizenship, CBP Approval Signature BLUE INK, CUSTOMS AND BORDER PROTECTION ONLY, SIDA Training Date, Badge Number, and Badge Access Level.

Stage number 2 for submitting airport badge application

You can potentially make an error while filling out your Country of Birth, and so make sure that you reread it prior to when you send it in.

3. The next part is going to be easy - complete all of the fields in Persons seeking unescorted access, Yes, Forgery of certificates false, Yes, Aircraft piracy, Yes, No Murder, Improper transportation of a, Interference with flight crew, No No Commission of certain crimes, Yes Yes, Yes Yes Yes Yes, No No, Assault with intent to murder, and Sedition Kidnapping or hostage in order to complete the current step.

Forgery of certificates false, Yes, and No Murder of airport badge application

4. Your next paragraph needs your information in the following places: I understand and agree to comply, MIA ACCESS CONTROL FORM Page of, and March. It is important to provide all needed info to move further.

airport badge application conclusion process clarified (step 4)

5. As you approach the final parts of this form, there are a few more things to complete. Mainly, Section IV Access Requirements to, New Applicant RenewalReplacement, Badge Type, Check the one that applies Green, Lime Orange Yellow White Blue, Special Certifications CBP Seal, Escort Authority, Extended Ajar, LEO, and I certify that this applicant is a should be filled out.

Filling out part 5 of airport badge application

Step 3: Reread the information you've inserted in the form fields and press the "Done" button. Make a 7-day free trial account with us and get direct access to airport identification badge - accessible in your personal account. We do not sell or share any details that you enter when completing documents at our website.

Miami Airport Badge Application Form isn’t the one you’re looking for?

Related Documents