===== PAGE 1 ===== # DETROIT METROPOLITAN WAYNE COUNTY AIRPORT AIRPORT ID BADGE APPLICATION ## SECTION I - APPLICANT (Print legibly - Use black or blue ink - No white out) Company Name: ___ Social Security #: ___ Nan. Full Name: Last (suffix) First Middle (full name) Date of Birth: Month / Day / Year Date of Hire: _____ Dept.: _____ Job Title: _____ Home Address: ___ Number Street (apt #, bldg. #, etc.) City State Zip Cell/Personal Phone Number: ___ Country of Citizenship: ___ Race: ___ Place of Birth: _____ Sex: _____ Eye Color: _____ Hair Color: _____ Height: _____ Weight: _____ State / Province / Country Email: ___ List any other names legally known by: (maiden, adopted, previously married, alias, etc.) First:___ Middle:___ Last:___ First: _____ Middle: _____ Last: _____ First:___ Middle:___ Last:___ Two (2) pieces of valid (unexpired) documentation are required for the badging process. Copies will not be accepted. At least one ID must have been issued by a government authority and at least one must include a photo. Applicant must provide documentation that establishes both identity (Table A) as well as employment eligibility (Table B). You must provide a document from both Table A and B. Please select the Table B document that reflects your citizenship.
TABLE A AND U.S. Citizens Born in U.S.TABLE B1 OR U.S. Passport or Expiration:TABLE B2 OR U.S. Citizens Born Outside U.S.TABLE B3 OR Non-U.S. Citizens
☐ Driver's License or ☐ State ID#:State of Issue:Expiration:U.S. Social Security Card#:U.S. Passport#: Expiration:Foreign Passport#: Issuing Country: Expiration: I-94 #: or I-551 #:
High School ID (with photo)
Passport#: Expiration:U.S. Passport#: Expiration:Employment Authorization Certificate from DHS#:Alien Reg. Number (ARN) from Employment Authorization or Permanent Residency Card: Expiration:
Alien Reg. Number (ARN) from Employment Authorization or Permanent Residency Card: Expiration:Original (or Certified copy) of U.S. birth certificate
Government ID (Ex: Military, DHS)
As the Authorized Signer, I have reviewed the above documentation to verify they are valid, unexpired, original, and legible. AUTHORIZED SIGNER - SIGNATURE DATE SECTION II – CREDENTIALS USE ONLY Application Received Date: ___ CT: ___ P: ___ S: ___ CC: ___ Ramp: ___ Escort: ___ Customs: ___ LEO: ___ STA Date:___ CHRC Disp.: Y/N Auth:___ FP Date Returned:___ Movement Date:___ SIDA Date: ___ Ramp Date: ___ ADA Date: ___ Insider Threat Date: ___ Vehicle Insp. Date: ___ Ops Tour Date: ___ Processed By: ___ Issued By: ___ Auth: ___ ===== PAGE 2 ===== # DETROIT METROPOLITAN WAYNE COUNTY AIRPORT AIRPORT ID BADGE APPLICATION ## SECTION III – 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 110-53, August 3, 2007); FAA Reauthorization Act of 2018, § 1934(c) (132 Stat. 3186, Public Law 115-254, Oct 5, 2018), and Executive Order 9397 (November 22, 1943), as amended. Recommendations of the 9/11 Commission Act of 2007, § 1520 (121 Stat. 444, Public Law 110-53, August 3, 2007); FAA Reauthorization Act of 2018, § 1934(c) (132 Stat. 3186, Public Law 115-254, Oct 5, 2018), and Executive Order 9397 (November 22, 1943), as amended. Purpose: The Department of Homeland Security (DHS) will use the information to conduct a security threat assessment. If applicable, 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 US-VISIT Automated Biometrics Identification System (IDENT). DHS will also maintain a national, centralized revocation database of individuals who have had airport- or aircraft operator-issued identification media revoked for noncompliance with aviation security requirements. DHS has established a process to allow an individual whose name is mistakenly entered into the database to correct the record and have the individual's name expunged from the database. If an individual who is listed in the centralized database wishes to pursue expungement due to mistaken identity, the individual must send an email to TSA at Aviation.workers@tsa.dhs.gov. Routine Uses: In addition to those disclosures generally permitted under 5 U.S.C. § 552a(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. § 552a(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 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: Pursuant to § 1934(c) of the FAA Reauthorization Act of 2018, TSA is required to collect your SSN on applications for Secure Identification Display Area (SIDA) credentials. For SIDA applications, failure to provide this information will result in denial of a credential. For other aviation credentials, although furnishing your SSN is voluntary, if you do not provide the information requested, DHS may be unable to complete your security threat assessment. I understand that any unanswered questions or incomplete information on this application will cause it to be rejected. 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). I agree to the taking of fingerprints and the conducting of a Criminal History Records Check. I understand the Airport will suspend the unescorted access privileges of anyone with an outstanding arrest warrant. I agree to adhere to all Airport Security rules and procedures and not violate any Federal Regulation or local Ordinances and I acknowledge that I understand the Security responsibilities under 49 CFR 1540.105(a). I understand that failure to comply with any of these rules is a security violation and may result in an Administrative Penalty and/or TSA civil penalty. By submitting this application and signing below, you consent; to being screened at any time while gaining access to, working in, or leaving a Security Sensitive Area; and that the information contained in this application may be shared with federal, state and local law enforcement agencies. PLICANT'S NAME: ___ SIGNATURE: ___ DATE: ___ NOTE: Badge Applications are held for processing and pick up of badges for 30 days only. Forms not processed, or badges not picked up within 30 days will be destroyed and re-application will be required ## SECTION IV – AUTHORIZED SIGNER I understand this application must be completed fully by the applicant then reviewed by me before I sign and date it. I affirm that the applicant has a need for unescorted access to Security Sensitive Areas and that all information on this application is correct and that sufficient administrative records are available for inspection by the TSA (Transportation Security Administration) or the Airport Authority and are maintained by my company as a matter of record. I acknowledge that the applicant understands their Security responsibilities under 49 CFR 1540.105(a) at DTW and will accept responsibility for any TSA fines levied against Detroit Metropolitan Wayne County Airport which are caused by the failure of any of my employees to adhere to the DTW Security Program. I understand that failure to comply with the requirements of this section will result in the termination of my authorizing authority, administrative penalties and possible TSA Civil Penalties. Airport ID Badges must be returned upon request, termination, or when access is no longer required. I will immediately notify the Airport of lost, stolen and/or terminated Airport ID Badges. AUTHORIZED SIGNER – PRINT NAME AUTHORIZED SIGNER - SIGNATURE DATE ## DTW BADGE # ## OFFICE PHONE # ## Employee Requested Certifications Please check the boxes that apply: AOA Ramp Driving Certification (Certification is needed to be eligible to drive on the ramp.) Escort Authority Certification (Certification is needed to be eligible to escort into Security Sensitive Areas.) Detailed justification is required for consideration. Please provide Escort Authority justification below: Employee Parking: None South Employee Lot North Employee Lot Both Employee Lots