Sd Form Id 01 – Fill Out and Use This PDF

DO NOT FOLD. Please type or print legibly using black or blue ink only. All pages must be legible or application will be voided.

Items 1 through 25 must be completed. Do not leave any section blank, write “N/A” for items that do not apply. Authorized Signatory must verify information.

1. LAST NAME

2. FIRST NAME

3. MIDDLE NAME

4. LIST ALL ALIAS/MAIDEN NAMES

5. HOME ADDRESS

6. CITY

7. STATE

8. ZIP CODE

9. COUNTRY OF ADDRESS

10. TELEPHONE #

11. HEIGHT

ft.

in.

12. WEIGHT

lbs.

13. GENDER

14. DATE OF BIRTH

15. DRIVER’S LICENSE/STATE ID #

16. STATE

17. EXPIRATION

18. COUNTRY OF CITIZENSHIP

19. U.S. STATE OR PLACE OF BIRTH

20. PASSPORT COUNTRY

21. PASSPORT #

22. I-9 DOCUMENTS

Non Immigrant VISA

I-94 Form (If checked, must complete # 23)

23. I-9 DOCUMENT #

24. ALIEN REGISTRATION #

25. U.S. CERTIFICATION OF BIRTH

Yes

No

ABROAD (DS-1350 or FS-545)

FOR AUTHORIZEDSIGNATORY USE ONLY.

DO NOT WRITE BELOW THIS LINE

Items 26 through 32 must be completed by the Authorized Signatory. Check all that apply.

26. REASON FORAPPLICATION:

New

Renew

Upgrade/Downgrade

Lost/Stolen

Damaged

Reactivate

BORN/NOV

27. BADGE TYPE REQUESTED:

SIDA/Ramp Access and Sterile Area

Non-SIDA/Sterile Area Only

Public

28. ESCORT PRIVILEGE:

Employee will escort

29. DRIVER PRIVILEGE:

Employee will drive on the airfield

30. U.S. CUSTOMS SEAL:

Red Seal

Black Seal

31. AUTHORIZED SIGNATORY:

Primary/Secondary Authorized Signatory

32. EMERGENCY RESPONSE:

ER Designation

FINGERPRINT CERTIFICATION

This employee has satisfactorily completed a Federal Bureau of Investigations fingerprint-based criminal history records check (TSR 1542.209).

Fingerprint Date:	Staff:	Case Number:

Company

Telephone

Authorized by (print)

Title (print)

Date

Signature

================================ FOR SECURITY OFFICE USE ONLY. DO NOT WRITE BELOW THIS LINE ==============================

FP Date

FP Staff

Non-Revenue

On Account

Credit Card

Check/MO#

FP Receipt #

Amount $

Badge Date

Badge Staff

Badge #

Billed

Non-Revenue

On Account

Credit Card

Badge Receipt #

Amount $

Check/MO#

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SD FORM ID-01 (11/2018)

SIDA TRAINING

This employee has satisfactorily completed an approved security awareness training program (TSR 1542.213)

	Date Completed	Staff	Company
	AIRPORT DRIVER SAFETY TRAINING		Contact Airport Operations for more information (404-530-6620)
	Any employee required to operate a motor vehicle on the Air
	Operations Area (AOA) must complete the Airport Driver Safety
	Training (ADST) course. The signed “AOA Driver Certified”
	stamp indicates the employee has satisfactorily completed an
	approved ADST course. The ADST course completion form		STAMP REQUIRED if driver privilege is checked
	must accompany this application for each badge
			(number 29)
	issuance/renewal.

SAFETY MANAGEMENT SYSTEM (SMS) TRAINING

This employee has successfully completed the required SMS training program.

Date Completed

Staff

Company

NON-SIDA EMPLOYEE/CUSTOMER SERVICE TRAINING

This employee has successfully completed the required Airport training program.

Date Completed

Staff

Company

AUTHORIZED SIGNATORY ANNUAL TRAINING

This Authorized Signatory has successfully completed the approved authorized signatory annual training (TSR SD 1542-04-08 series).

Date Completed

Staff

Company

EMPLOYEE RESPONSIBILITIES

1.I fully acknowledge my security responsibilities as outlined in 49 CFR 1540.105(a), security responsibilities of employees and other persons, and will comply with all Airport security rules. I further understand that I may lose my access privileges or be subject to civil penalties for violating these rules.

2.My security identification badge remains the property of the City of Atlanta Department of Aviation.

3.My security identification badge is not transferable to other individuals.

4.My security identification badge must, at all times, be visibly displayed on the outermost garment, waist high or above, while in the security and/or sterile areas.

5.I must challenge individuals who are not displaying their security identification badge and/or report the observation to my supervisor, the Airport police at 911 or Airport communications at (404) 530-6800. I must ensure that the individual(s) is properly escorted from the area or released to the proper authority.

6.I must immediately notify my supervisor and Airport Security Access Control at (404) 274-0368, Airport Security Compliance and Enforcement at (404) 326-8495 / (404) 561-6416, or Airport Communications at (404) 530-6800 of the loss or theft of my security identification badge. In the event of the loss of my security identification badge, a badge replacement fee will be assessed and will be collected by Airport security staff before a replacement security identification badge is issued.

7.My security identification badge is issued to support my job duties and responsibilities at the Airport and should be used for official business purposes only. I will never use my security identification badge for personal or off-duty use.

8.I understand that the City of Atlanta Department of Aviation reserves the right to revoke the authorization of individuals with security identification badges where such actions are determined to be in the best interest of Airport security.

9.I will return my security identification badge to my company or Airport security within twenty-four (24) hours when it is no longer required for the performance of my duties at ATL.

10.I must disclose to the Airport Security Coordinator and/or supervisor within twenty-four (24) hours if I am charged and/or convicted of any disqualifying criminal offense that occurs while I am in possession of an ATL Badge.

11.All employees traveling as passengers must access the sterile area through a TSA screening checkpoint. Once screened, employees must remain in the sterile area with any accessible property until they board the aircraft. This requirement applies when traveling for all purposes (business, leisure, etc.) unless exempt by federal regulation.

Employee Signature

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SD FORM ID-01 (11/2018)

PRIVACY ACT NOTICE 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); 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. 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). 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 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 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: 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.

EMPLOYEE CERTIFICATION STATEMENT

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 the Title 18 of the United States Code).

I authorize the social security administration to release my social security number and full name to the Transportation Security Administration Office of Transportation Threat Assessment and Credentialing (TTAC). 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 or imprisonment or both.

	/			/
Employee Signature			Date of Birth
	-			-
Employee Full Name (print)			SSN

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SD FORM ID-01 (11/2018)