Tsa Form 2212 – Fill Out and Use This PDF

The TSA Form 2212, known as the TWIC Disclosure and Certification form, is a crucial step for individuals needing a Transportation Worker Identification Credential (TWIC). This form begins the process of a security threat assessment required for those with unescorted access to secure maritime facilities or vessels, allowing the Transportation Security Administration (TSA) to verify an applicant's identity and eligibility. To complete your enrollment for a TWIC, ensure all the necessary information and documentation are provided by clicking the button below.

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Tsa Form 2212 PDF Details

The TSA 2212 form, integral to the process of obtaining a Transportation Worker Identification Credential (TWIC), is centered on a comprehensive security threat assessment mandatory for individuals requiring unescorted access to secure maritime areas or vessels. Designed to validate identity and eligibility, the form demands that applicants share specific information and present documents corroborating their identity during enrollment. Upon completion, the form must be submitted in person, laying the groundwork for a meticulous vetting process. In cases where an applicant is initially deemed ineligible, a "Preliminary Determination of Ineligibility" notification is issued, offering pathways for appeal or waiver application, where additional documentation can be presented in favor of an applicant's eligibility. Furthermore, the form meticulously details the requirements for disclosure, including criminal history, which serves as a critical filter to identify any potential security threats. It underscores the significance of providing truthful information and the implications of failing to do so, including the possibility of fines, imprisonment, or both. This enforceability reaffirms the form's purpose in safeguarding maritime facilities and vessels by ensuring that individuals granted access do not pose a security threat.

Question	Answer
Form Name	Tsa Form 2212
Form Length	4 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min
Other names	online twic application, printable twic card application, twic card application form, twic card application

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TWIC Disclosure and Certification

INSTRUCTIONS: If you must obtain a Transportation Worker Identification Credential (TWIC), you are required to undergo a security threat assessment. To undergo this assessment, all applicants must provide information requested below and the appropriate documentation to verify their identity and eligibility as part of enrollment. Completed forms must be submitted in person at the beginning of the enrollment process. If you are initially deemed ineligible, you will receive a "Preliminary Determination of Ineligibility" letter. You may then be eligible to appeal or apply for a waiver. If you apply for an appeal, you have lhe opportunity to provide documentation to TSA that corrects incomplete or incorrect information. If you apply for a waiver, you have the opportunity to provide additional information/documentation to TSA in support of your eligibility. [Note: if you are currently under indictment or have open felony charges, it is recommended that you wait to apply for a TWIC until the matter is resolved.]

SECTION I - DISCLOSURE

Part A. Acknowledgments - Review each statement and respond by checking Yes or No, as appropriate.

1.I am:

•required to have unescorted access to secure areas of maritime facilities or vessels in which a 1WIC is required; or

	• applying to be a credentialed merchant mariner; or	DYes DNo
	• applying to be a credentialed merchant mariner; or
	• a commercial driver licensed in Canada or Mexico transporting hazardous materials in accordance with 49
	CFR 1572.201 ; or
	• authorized by TSA to complete the 1WIC security threat assessment and/or apply for a TWIC.
	2. I understand that if I plan on applying for or renewing a Coast Guard (CG)-issued merchant mariner credential.
	but do not provide my Social Security Number and proof of citizenship during enrollment, I will be required to	DYes DNo
	visit a CG Regional Examination Center to provide this information before my application for the CG-issued	DYes DNo

	credential w ill be considered complete.

	3. I acknowledge that if the Transportation Security Administration (TSA) or another law enforcement agency
	determines that I pose a security threat, my employer may be notified of this information. As such, TSA may	DYes 0No
	provide limited information necessary to reduce the risk of injury or damage to any affected area or facility.

	4. I understand that since the 1WIC will serve as a visual identification badge, items or attire should not obscure
	any part of my face when my photograph is taken . As a result, I acknowledge that:
	• I will remove a hat or headgear unless worn daily for religious reasons.	DYes D No

•I will remove glasses with tinted lenses, unless they are required to be worn at all times for medical reasons. If so, a medical certificate may be required .

5.I am: (check the box that applies)

D a U.S. Citizen or U.S. National; or

·D not a U .S. Citizen or U.S . National, but fall into a category listed on page 3 and am eligible for a 1WIC.

6.	I currently hold a 1WIC.	DYes DNo
7.	I understand that when I pick up my renewal/replacement 1WIC, I am responsible for turning in my

previous 1WIC.	D Yes D No

Part B. Criminal History- Review each statement and respond by checking Yes or No, as appropriate. (Please refer to page 4)

1.At any time in my life (excluding juvenile cases unless convicted as an adult), I was convicted or pled guilty (including "no contest"/nolo contendere) or found not guilty by reason of insanity in a civilian or military court of one or more of the following felonies:

•	Espionage or conspiracy to commit espionage;	•	Treason or conspiracy to commit treason: or
•	Sedition or conspiracy to commit sedition;	•	A federal crime of terrorism as defined in 18 U.S.C.
			2332b(g), or a comparable State law.

Note: If you answer "Yes," you are not eligible to receive a TWIG and/or a waiver.

2.At any time in my life (excluding juvenile cases unless convicted as an adult), I was convicted , pled guilty (including "no contest"/nolo contendere), or found not guilty by reason of insanity in a civilian or military court of any of the following felonies:

• A crime involving a transportation security incident;	•	Murder;
• Improper transportation of a hazardous material;	•	Making a threat or maliciously conveying false
Unlawful possession, use, sale, distribution,		information known to be false, concerning delivery,
manufacture, purchase. receipt, transfer. shipping,		placement, or detonation of an explosive or other
transporting, import, export, storage of. or dealing in		lethal device in a public, government, public
an explosive or explosive device . An explosive or		transportation, or infrastructure facility;
explosive device includes, but is not limited to, an	• RICO Act violations where a predicate act is a crime
explosive or explosive material as defined in 18		listed in Parts 81 and 82;
U.S.C. 232(5), 841(c) through 841(f), and 844U); and	• Attempt to commit a crime listed in Parts 81 ; or
a destructive device, as defined in 18 U.S.C.		Conspiracy or attempt to commit a crime listed in
921(a)(4) and 26 U.S.C. 5845(f).		Part 82.

DYes D No

Previous editions o..f this form are obsolete.

TSA Form 22 12, Ma rch 2013	Page l of 4
	OMB 1652-0047. which expires 09/ 30/20 13

3. Within the last I years, I was convicted, pled guilty (including "no contest"/nolo contendere), or found not guilty					DYes D No
	by reason of insanity in a civilian or military court of any of the following felonies:				DYes D No


	•	Unlawful possession, use, sale, manufacture,	• Smuggling;
		purchase, distribution, receipt, transfer, shipping,	•	Immigration violations;
		transporting. delivery, import, export of, or dealing in	.Distribution of, possession with intent to distribute, or
		a firearm or other weapon. A firearm or other		importation of a controlled substance;
		weapon includes, but is not limited to, firearms as	•	Arson:
		defined in 18 U.S.C. 921(a)(3) or 26 U.S.C. 5 845(a),	• Kidnapping or hostage taking;
		or items contained on the U.S. Munitions Import List	.Rape or aggravated sexual abuse;
		at 27 CFR 447.21.	.Rape or aggravated sexual abuse;
		at 27 CFR 447.21.	• Assault with intent to kill;
	•	Extortion;	• Assault with intent to kill;
	•	Extortion;	•	Robbery;
	•	Dishonesty, fraud, or misrepresentation, including	•	Robbery;
	•	Dishonesty, fraud, or misrepresentation, including	• Fraudulent entry into secure seaport areas;
		identity fraud and money laundering (except welfare	• Fraudulent entry into secure seaport areas;
		identity fraud and money laundering (except welfare	.RICO; or
		fraud and passing bad checks);	.RICO; or
	•	Bribery;	• Conspiracy or attempt to commit the crimes listed in
	•	Bribery;		Part 83.
				Part 83.
3.	Within the last .§. years, I was released from prison following conviction for a felony listed in Part 8 3.				D	Yes D	No

4.	A civilian or military cou rt has found me to lack mental capacity or I have been involuntaril y committed to a				D Yes DNo
	mental health facility.				D Yes DNo
	mental health facility.
5. I am wanted, under indictment or have an open criminal complainUcriminal information in a civilian or military					D	Yes D	No
	court for a felony listed in Parts 81 through 83.				D	Yes D	No
	court for a felony listed in Parts 81 through 83.

		Note: If you answered "Yes" to any of the statements listed in Parts 82 through 84 , you are eligible to
		request a waiver and may still be issued a lWIC. If you answered "Yes'to Part 85 because you are
		currently under indictment or have open criminal charges, you should consider waiting to apply for a
		lWIC until these matters are resolved as enrollment fees are not refunded.
6.	If initially denied for a lWIC, I plan on applying for a waiver.				D	Yes D	No

7.I understand that I must return my lWIC to the address provided on the credential if 1:

• am currently, or become, wanted, under indictment for, convicted, or found not guilty by reason of insanity, of

a felony listed in Parts 81 through 83;

DYes D No

•am found to be lacking mental capacity or involuntarily committed to a mental health facility; or

•no longer meet the immigration standards indicated by a "Yes" response in Part A5.

SECTION II -CERTIFICATION

Please review and certify the responses provided in this form by printing and signing your name with a date. If help/translation assistance is provided, contact information for the helper/translator is required should follow up be necessary. For applicants and helpers/translators, a knowing and willful false statement or an omission of a material fact in th is form is punishable by fine or imprisonment or both (see 18 U.S.C. 1001 ), and may be grounds for denial of a TWIC.


Applicants: The information I have provided on this form is		Helpers/Translators: I certify that I provided assistance in the
true, complete, and correct to the best of my knowledge and		completion of this form at the request of the named applicant;
belief and is provided in good faith.		the responses provided are based on information of which I
		have knowledge or which was provided to me by the applicant;
		and I have read the completed form to the applicant in the
		language he/she speaks fluently for verification before he/she
Printed Name of TW/C Applicant
Printed Name of TW/C Applicant		signed the application in my presence.
		signed the application in my presence.

Signature of TWIC Applicant	Date	Printed Name of He/per/Translator

Daytime Telephone		Signature of Helper/Translator		Date

Email Address		Daytime Telephone
	. .		. .
	. .		. .

PRIVACY ACT STATEMENT: Authority: The authonty for collecting lh1s mformation IS 49 U.S.C.114, 40113, and 5103a. Pnnc1pal Purpose(s): Th1s mformahon IS needed to venfy

your identity and to conduct a security threat assessment to evaluate your suitability for a TWIG . Furnishing this information, including your SSN or alien registration number, is voluntary; however, all information provided during the enrollment process assists in the timely processing or your application. Failure to provide it will delay and may prevent completion or your security threat assessment. For Individuals who are mariners or applying to be one, the SSN is mandatory or they will be required to visit a Coast Guard Regional Exam Center to this information before an application is complete. Routine Use(s): Routine uses of this information Include disclosure to the FBI to retrieve your criminal history record; to TSA contractors or other agents who are providing services relating to the security threat assessments: to appropriate governmental agencies for licensing, 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. PAPERWORK REDUCTION ACT STATEMENT: TSA is collecting this information to determine your eligibility for a TWIG. This is a voluntary collection of information but failure to provide the information may result in an inability to approve your eligibility for a TWIG. TSA eslimates that the total average burden per response associated with this collection for enrollment is approximately one (1) hour. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The control number assigned to this collection is OMS 1652.{)047, which expires 09/30/2013.

	Previous editions ofthis.form are obsolete.
TSA Form 2212. March 20 13	Page 2 of4
TSA Form 2212. March 20 13	OMB 1652-0047 , which expires 09/30/2013

I am not a U.S. citizen or national, but fall into a category listed below which permits me to hold a TWIC

1.Lawful permanent resident (LPR) of the U.S.

2.Refugee admitted under 8 U.S.C. 1157.

3.Alien granted asylum under 8 U.S.C. 1158.

4.Citizen of Micronesia, Marshall Islands, or Palau.

5.Commercial driver who is a citizen of and licensed in Canada or Mexico to transport hazardous materials or admitted to U.S. to conduct business under 8 CFR 214.2(b)(4)(i)(E).

6.Alien in valid F-1 non-immigrant status enrolled at the U.S. Merchant Marine Academy or comparable State maritime academy and sponsored by the U.S. Maritime Administration (MARAD).

7.Alien in valid J-1 non-immigrant status enrolled at the U.S. Merchant Marine Academy or comparable State maritime academy and sponsored by MARAD.

8.Alien in valid M-1 non-immigrant status enrolled at the U.S. Merchant Marine Academy or comparable State maritime academy.

9.Alien in valid R-1 (Religious Workers) status sponsored by

MARAD.

10. Alien in a lawful nonimmigrant status with unrestricted authorization to work in the U.S. holding one of the following visas:

-A-1: Principal alien and immediate family members of an Ambassador, Public Minister, Career Diplomat, Consular Officer, Head of State, with a bilateral agreement in place;

-A-2: Principal alien and immediate family members of other foreign government officials or employees coming to the United States, including technical and support staff of A-1 , with a bilateral agreement in place;

-A-13 or A-14: Family unity;

-E-1: Spouse and dependent children of an treaty trader;

-E-2: Spouse of a treaty investor or employee of a treaty investor spouse;

-G-1: Principal alien and immediate family member of a principal resident representative of recognized foreign member government to international organization and staff, with a bilateral agreement in place;

-G-3: Principal alien and immediate family member of a representative of a non-recognized or nonmember foreign government to international organization, with a bilateral agreement in place;

-G-4: Principal alien and immediate family member of an International organization officer or employee with a bilateral agreement;

-J-2: Spouse or minor child of exchange visitor;

-K-3: Spouse of U.S. Citizen (under LIFE Act provisions);

-K-4: Child of K-3;

-L-2: Spouse or child of L-1;

-N-8: Parent of alien classified SK-3 "special immigrant";

-N-9: Child of N-8, SK-1, SK-2, or SK-4 "special immigrant";

-Principal alien and immediate family members of North Atlantic Treaty Organization (NATO) officials and representatives with bilateral agreement in place: NAT0- 1, NAT0-2, NAT0-3, NAT0-4, NAT0-5, NAT0-6;

-S-7: Spouse, unmarried sons and daughters, and parents of witness or informant;

-T-1: Victim of a severe form of trafficking in persons;

-T-2: Spouse of victim of a severe form of trafficking in persons:

-T-3: Child of victim of a severe form of trafficking in persons;

-T-4: Parent of victim of a severe form of trafficking in persons (if T-1 is under 21 years of age);

-T-5: Unmarried sibling under age of 18 of a T-1 under ageof21;

-TPS: Temporary protected status (TPS);

-U-1: Victim of certain criminal activity;

-U-2: Spouse of U-1 ;

-U-3: Child of U-1;

-U-4: Parent of U-1 (if U-1 is under 21 years of age);

-U-5: Unmarried sibling under age 18 of a U-1 under age 21;

-V-1: Spouse of an LPR who is the principal beneficiary of a family-based petition which was filed prior to December 21, 2000, and has been pending for at least 3 years;

-V-2: Child of an LPR who is the principal beneficiary of a family-based visa petition that was filed prior to December 21, 2000, and has been pending for at least 3 years; OR

V-3: The derivative child of a V-1 or V-2.

11.Alien with restricted authorization to work in the U.S. holding one of the following visas:

•B1-0CS: Business visitor/outer continental shelf (OCS);

•B-1 or B-1/B-2 with 'lWICLetter Received'annotation: Business visitor requiring a TWIC;

•BBBCV: B-1/B-2 and Border Crossing Card (Mexicans only);

•C-1/D: Combined transit and crewman visa;

•E-1 (Principal): Treaty trader or employee of treaty trader;

•E-2 (Principal): Treaty investor, or employee of treaty investor;

•E-3: Australian nationals working in specialty occupations, including spouse;

•E-3 D: Spouse or child of E-3;

•E-3R: Returning National of Australia who are professionals coming to the U.S. to perform services in a specialty occupation to uninterrupted employment;

•H-1 B: Specialty occupations;

•H1-B1: Specialty occupations (professional) (Citizens of Chile or Singapore only)

•L-1: Intracompany transferees;

•L-1A: Executive, managerial (intracompany transferee);

•L-1 B: Specialized knowledge professionals;

•0-1: Extraordinary ability;

•0-1A: Extraordinary ability in sciences, arts, education, business, or athletics;

•0-1 B: Extraordinary achievement in motion picture and/or television productions; OR

•TN: Trade visas for Canadian and Mexican business persons seeking to engage in professional activities under the North American Free Trade Agreement (NAFTA).

NOTE: The following visa types with unrestricted work authorization are not permitted to obtain a TWIC:

•K-1: Fiance or fiancee of U.S. citizen;

•K-2: Minor child of K-1.

•S-5: Informant of criminal organization information: OR

•S-6: Informant of terrorism information.

Previous editions ofthis form are obsolete.

TSA Form 2212, March 2013	Page 3 of4	OMB 1652-0047, which expires 09/30/2013

Disqualifying criminal offenses (49 C.F.R. 1572.103)

COLUMNA

Conviction for one of the following felonies is disqualifying regardless of when it occurred, and the applicant is not eligible for a waiver.

1.Espionage or conspiracy to commit espionage.

2.Sedition, or conspiracy to commit sedition.

3.Treason, or conspiracy to commit treason.

4.A federal crime of terrorism as defined in 18 U.S.C. 2332b(g), or comparable State law, or conspiracy to commit such crime.

Conviction for one of the following felonies is disqualifying regardless of when it occurred, and the applicant may apply for a waiver.

5.A crime involving a transportation security incident. A transportation security incident is a security incident resulting in a significant loss of life, environmental damage, transportation system disruption, or economic disruption in a particular area, as defined in 46 U.S.C. 70101. The term "economic disruption" does not include a work stoppage or other employee-related action not related to terrorism and resulting from an employer-employee dispute.

6.Improper transportation of a hazardous material under 49 U.S.C. 5124, or a State law that is comparable.

7.Unlawful possession, use, sale, distribution, manufacture, purchase, receipt, transfer, shipping, transporting, import, export, storage of, or dealing in an explosive or explosive device. An explosive or explosive device includes an explosive or explosive material as defined in 18 U.S.C. 232{5), 841 (c) through 841 (f), and 8440); and a destructive device, as defined in 18 U.S.C. 921 {a)(4) and 26 U.S.C. 5845{f).

8.Murder.

9.Making any threat, or maliciously conveying false information knowing the same to be false, concerning the deliverance, placement, or detonation of an explosive or other lethal device in or against a place of public use, a state or government facility, a public transportations system, or an infrastructure facility.

10.Violations of the Racketeer Influenced and Corrupt Organizations Act, 18 U.S.C. 1961, et seq., or a comparable State law, where one of the predicate acts found by a jury or admitted by the defendant, consists of one of the crimes listed in Column A.

11.Attempt to commit the crimes in Column A, items 1 - 4.

12.Conspiracy or attempt to commit the crimes in Column A, items 5-10.

COLUMNS

Conviction for one of the following felonies is disqualifying if the applicant was convicted, pled guilty (including "no contest'?, or found not guilty by reason of insanity within 7 years of the date of the TWIC application; OR if the applicant was released from prison after conviction within 5 years of the date of the application. The applicant may apply for a waiver.

1.Unlawful possession, use, sale, manufacture, purchase, distribution, receipt, transfer, shipping, transporting, delivery, import, export of, or dealing in a firearm or other weapon. A firearm or other weapon includes, but is not limited to, firearms as defined in 18 U.S.C. 921{a){3) or 26 U.S.C. 5 845(a), or items contained on the U.S. Munitions Import List at 27 CFR 447.21.

2.Extortion.

3.Dishonesty, fraud, or misrepresentation, including identity fraud and money laundering where the money laundering is related to a crime described in Columns A or B. Welfare fraud and passing bad checks do not constitute dishonesty, fraud, or misrepresentation for purposes of this paragraph.

4.Bribery.

5.Smuggling.

6.Immigration violations.

7.Distribution of, possession with intent to distribute, or importation of a controlled substance.

8.Arson.

9.Kidnapping or hostage taking.

10.Rape or aggravated sexual abuse.

11.Assault with intent to kill.

12.Robbery.

13.Fraudulent entry into secure seaport areas as described in 18 U.S.C. 1036, or a comparable State law.

14.Violations of the Racketeer Influenced and Corrupt OrganizationsAct,18 U.S.C.1961, etseq., ora comparable State law, other than the violations listed in Column A, item 10.

15.Conspiracy or attempt to commit felonies listed in Column B.

Previous editions ofthis form are obsolete.

TSA Form 2212, March 2013	Page 4 of4
	OMB 1652-0047, which expires 09/30/2013

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Fill out the At any time in my life excluding, including no contestnolo, DYes D No, Espionage or conspiracy to commit, Treason or conspiracy to commit, Note If you answer Yes you are not, bg or a comparable State law, At any time in my life excluding, including no contestnolo, Murder Making a threat or, Unlawful possession use sale, information known to be false, RICO Act violations where a, listed in Parts and, and Attempt to commit a crime listed area using the details demanded by the application.

stage 2 to entering details in form 2212

It's essential to put down certain details inside the segment Within the last I years I was, by reason of insanity in a, DYes D No, Unlawful possession use sale, purchase distribution receipt, Extortion Dishonesty fraud or, identity fraud and money, Bribery, Smuggling Immigration violations, Distribution of possession with, importation of a controlled, Arson Kidnapping or hostage, Rape or aggravated sexual abuse, Assault with intent to kill, and Conspiracy or attempt to commit.

The field am currently or become wanted, a felony listed in Parts through, am found to be lacking men tal ca, DYes D No, SECTION II CERTIFICATION, Please review and certify the, HelpersTranslators I certify that, Printed Name of TWC Applicant, Signature of TWIC Applicant, Date, Printed Name of HeperTranslator, Daytime Telephone, Signature of HelperTranslator, Date, and Email Address will be for you to place each side's rights and obligations.

Step 3: Hit "Done". Now you can export your PDF form.

Step 4: It is simpler to maintain copies of your form. You can rest assured that we will not reveal or read your information.

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