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DETROIT METROPOLITAN WAYNE COUNTY AIRPORT AUTHORIZED SIGNER LIST
Company Name: ___ Department: ___
Company Name
Department
Mailing Address: ___
Mailing Address
undefined
Email: ___ Phone: ___ Fax: ___
Email
Phone
Fax
By TSA regulations, only Airport Authorized Signers, as certified by the Airport Operator, are granted the authority to request Airport issued ID Badges for access to the Airport's Security Sensitive Areas. Those individuals seeking to be allowed to "authorize" Airport ID Badge Applications and to make security requests and approvals for their company must read and agree to the following before being certified by the Airport:
I affirm that all information on Applications submitted under my authorization will be completed and reviewed prior to authorizing it and I will not knowingly sign or submit an Application that contains information that is false or misleading.
I understand that by TSA regulations I must be in possession of an Airport Photo ID Badge to be permitted to authorize Badge Applications and I will undergo recurrent Authorized Signer Training annually through the Airport's Credentials Office. I must notify Airport Security immediately if I separate from my company or if I become aware that others from my company who possess active ID Badges are separated. In addition, I will notify the Airport if a company I sponsored no longer needs access to the Airport or whose contract has expired.
I affirm that our company will maintain administrative records until at least 180 days after separation regarding each Badged employee and will make these records available to the Airport Authority or TSA for inspection to determine compliance with all security requirements. The records shall include, but not be limited to the following:
A copy of the Badge Application.
A copy of the Badge Separation Form for all non-active employees.
Any other information as required by the Chief Executive Officer, or designee.
The records will be maintained at: Address: ___
Address [1]
Address [2]
The records will be maintained by: Name: ___
Name
Phone: Email:
Phone:
Name:
I affirm that prior to authorizing an application, I have reviewed with each applicant to attest that they have not been arrested, charged or been convicted of one of the disqualifying crimes as identified on the fingerprint form. In addition, I will report to the Airport within 24 hours if I, or any employee, who currently possesses an Airport Photo ID has been arrested, charged or convicted for one of those crimes.
I will make my employees aware of the Security rules and procedures at DTW and acknowledge responsibility for any TSA fines levied against Detroit Metropolitan Wayne County Airport, which are caused by the failure of myself or one of my employees to adhere to the DTW Security Program.
I understand that failure to comply with the requirements of this certification may result in the termination of my, and/or my company's, authorized authority and access privileges and may subject me or my company to possible Airport Administrative or TSA Civil Penalties. I understand that there may be penalties and fines if Badges are not deactivated or returned in a timely manner.
Airport Security
Detroit Metropolitan Wayne County Airport – Building 610 – 31399 East Service Drive – Detroit, MI 48242 Phone: (734) 942-3606 Fax: (734) 942-3814 Email: Security@wcaa.us
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AUTHORIZED SIGNER LIST FOR AIRPORT ID BADGE ISSUANCE
FOR AIRPORT ID BADGE ISSOANCE
The following individuals agree to the terms and conditions as identified on this form and are authorized to sign for issuance of Airport Identification Badges for
issuance of Airport Identification Badges for ___________________________________.
PRINT NAME
Company Name
TITLE
DTW BADGE
DATE
1. PRINT NAME SIGNATURE
OFFICE NUMBER
CELL NUMBER
EMAIL
TITLE DTW BADGE # DATE
OFFICE NUMBER CELL NUMBER EMAIL
PRINT NAME
2. PRINT NAME SIGNATURE
TITLE
DTW BADGE
DATE
TITLE DTW BADGE # DATE
OFFICE NUMBER
CELL NUMBER
EMAIL
OFFICE NUMBER CELL NUMBER EMAIL
PRINT NAME
3. PRINT NAME SIGNATURE
DATE
TITLE
DTW BADGE
TITLE DTW BADGE # DATE
OFFICE NUMBER
CELL NUMBER
EMAIL
OFFICE NUMBER CELL NUMBER EMAIL
PRINT NAME
4. PRINT NAME SIGNATURE
TITLE
DTW BADGE
DATE
TITLE DTW BADGE # DATE
OFFICE NUMBER
CELL NUMBER
EMAIL
OFFICE NUMBER CELL NUMBER EMAIL
5. PRINT NAME SIGNATURE
PRINT NAME
TITLE DTW BADGE # DATE
TITLE
DTW BADGE
DATE
OFFICE NUMBER CELL NUMBER EMAIL
OFFICE NUMBER
CELL NUMBER
EMAIL
All signatures contained on this form must be physically signed. Stamped or computer-generated signatures will not be accepted.
AIRPORT USE ONLY
Airport Approval: Credentials Manager
Company Type: Primary Color: Secondary Color: Codes:
Airport Security Detroit Metropolitan Wayne County Airport – Building 610 – 31399 East Service Drive – Detroit, MI 48242 Phone: (734) 942-3606 Fax: (734) 942-3814 Email: Security@wcaa.us