City of Chicago Department of Aviation ACCESS CONTROL AND PHOTO ID BADGE APPLICATION Step 1 - Application Information To be completed by the APPLICANT 1 Application Airport: O Hare (ORD); CAT X Midway Airport (MDW); CAT 1 Previous City of Chicago employment? YES 2 Company Name: Company Code: NO 3 Application Type RENEWAL NEW ID CHANGE LOST STOLEN DF #: DAMAGED 4 Company Type AIRLINE or 5 CONCESSIONS CONSTRUCTION GOVERNMENT SUB- VENDOR CONTRACTOR 6 7 Do you have any nicknames or aliases? NO YES Maiden/Alias 1. Alias 2. Alias 3. Social Security Number: (9 digits, no dashes) (submission is voluntary, although failure to provide it may delay or prevent completion of the security threat assessment) Date of Birth: Home Address: Daytime Telephone Number 8 City: State: Zip Code: Country: Current Mailing Address (if different from home address above)no P.O. Boxes: E-mail address (if applicable) 9 City: State: Zip Code: 10 Gender: Male Female Race: Asian Black Native American Unknown Caucasian/Latino 11 Height: FEET INCHES Weight: LBS Natural Hair Color: Natural Eye Color: 12 Brown Black Blonde Red Gray White None Black Blue Brown Hazel Green Gray If at above address for less than 5 years, list previous address: 13 City of Birth State County and Country of Birth (country name and code): 14 Are you a US Citizen? NO YES Country of Citizenship: Are you authorized to work by the Government of the United States? NO YES Certification of Birth Abroad, Form DS-1350, or 10 digit document number (no dashes): DS 15 Alien Registration Number or USCIS Number (Referred as ARN or INS No.) (9 digits, no dashes) : Non-Immigrant Visa Control Number (if applicable): I-94 Arrival/Departure Form Number (11 digits, no dashes) (if applicable): Passport Country: Passport Number: Passport Expiration 16 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 authorize the Social Security Administration to release my Social Security Number and full name to the Transportation Security Administration, Office of Intelligence and Analysis (OIA), Attention: Aviation Programs (TSA-10)/Aviation Worker Program, 601 South 12 th Street, Arlington, VA 20598. I am the individual to whom the information applies and want this information released to verity 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. Signature: SSN: Full Name: Date of Birth: 4/1/2018 1
17 The Privacy Act of 1974, 5 U.S.C. 552a(e)(3) 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 the fingerprints for enrollment into the US-VISIT s 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 s 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/biometrics 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. Chicago Airport System Photo ID Badge and Access Control Badge Holder Agreement I will comply with all airport and federal rules and regulations governing my access privileges to the Security Areas including the Secured Area, SIDA, Sterile Area and Air Operations Area; including my authority to authorize others to have access to these security areas as presented to me by the TSA approved SIDA Training Course, including: ID badges are not transferable and must be displayed on the outermost garment, above the waist and below the neck at all times. I understand that the badge is the property of the City of Chicago and must be surrendered upon demand, resignation, dismissal or suspension. I will not alter or deface the badge in any way, including punching holes in the badge or affixing stickers to the badge. I must report any attempts to use an altered or expired badge. I must challenge and/or immediately report any individual I find in the SIDA without proper authorization or who is not displaying a proper ID to my supervisor, the Chicago Police or Aviation Security, or any other entity charged with security responsibilities. I must immediately report a lost/stolen ORD or MDW ID badge to the Airport Communication Center. I understand that all vehicles, property and persons are subject to search by the TSA, Chicago Police Department and/or Aviation Security. I will return my badge to the Chicago Department of Aviation when access privileges in excess of 30 days are no longer required. I agree to abide by the City of Chicago Department of Aviation Ground Vehicle Operating Regulations. I understand that I am subject to fines and revocation of driving and/or badging privileges for violating regulations enforced by the Department of Aviation. When travelling as a passenger, I must access the Sterile Area through the TSA screening checkpoint, including Known Crew Member checkpoints with any accessible property I intend to carry onboard the aircraft and remain in the Sterile Area after entering. X Applicant s Signature Step 2 - Employer s Information To be completed by the above applicant s EMPLOYER 18 Employee s Hire Employee s Job Title: 19 Supervisor s Full Name: 20 Work Telephone: Fax Telephone: The employee s job duties require access to the following security areas: 21 BLUE Public Safety Credential Authorization PRINT NAME Signature GREEN - Secured Area and AOA Access. GREY AOA Access, MDW FBO, MDW General Aviation access. PURPLE Sterile Area access located beyond the passenger screening checkpoint(s). YELLOW Parking ONLY Airline Employee ID: ESCORT PRIVILEGES REQUIRED YES NO REQUEST FIS ACCESS y US CUSTOMS HOLOGRAM (requires separate US Customs authorization form) 22 23 Do the employee s job duties require him/her to drive on the airfield? YES NO If the employee fails the Drivers Test, is it OK to badge employee without the driving privileges stripe? YES NO Level of driving stripe required by employee s duties: BASIC, Yellow: Non-Movement Areas ONLY (service roads, ramp areas only) ADVANCED, Red: Non-movement and Movement Areas (service roads, ramps, runways and taxiways) TAXI, Blue: Movement Area Access (aircraft mechanic taxiing aircraft in or across the Movement Area) 24 Employee s Driver s License /State ID Number: State: Expiration 4/1/2018 2
25 Employer Certification I certify to the City of Chicago, in accordance with TSAR Part 1540, and attest under penalty and perjury that the employee s information provided in block 15 of this application is true and complete to the best of my knowledge. Further, I certify that documents of identification, employment eligibility and citizenship pertaining to the applicant have been verified and appear genuine. I also certify that the individual has been hired as an employee of the company and, except for the receipt of an ID badge, has met all of the company s hiring qualifications. I will immediately notify the Department of Aviation when the employee above no longer meets employment eligibility, including but not limited to, suspension, termination, or resignation, or if there has been a change in the employee s identity and will confiscate his/her ID badge or be subject to fines and prosecution. If driving privileges are required for the employee: I also certify that the employee above holds a valid driver s license and will receive appropriate training for the operation of a motor vehicle or equipment in the Air Operations Area and Secured Area. X Print Name Badge# Telephone Number: Step 3 - Tenant Information To be completed by the only 26 Contract Verification: The contract for this contractor, sub-contractor, or vendor is active and will expire on: / / Badge cannot be issued beyond this date. 27 Access Code Assignment 28 Airline Fingerprint Information Please route Fingerprint Results via our SON to the FAA Secured Web board; SON # Enter the date you received the results: / / Enter OPM Case # belonging to cleared results: I hereby certify that all conditions of TSA Regulation 1540, 1542, 1544 and 1546 have been met. I further certify that the organization I represent assumes responsibility for all fines or other penalties imposed by the TSA upon the City of Chicago Department of Aviation for any violation(s) by this applicant. I understand and have read the ID Badging Handbook issued by the City of Chicago, Department of Aviation. I also agree to assume responsibility for the fines imposed upon the employer for violation of TSA Regulations and Department of Aviation Rules and Regulations. 29 Furthermore, if Driver Designation is requested, I certify that the applicant will receive appropriate training as it relates to the Ground Motor Vehicle Operating Rules and in relation to the level of job responsibilities that the applicant will perform. X Print Tenant Name Badge# Telephone Number: X Tenant Signature: Primary CDA OFFICE USE ONLY Secondary 30 Identification Verification 31 Driver Test Information US Passport State Drivers License Social Security Card State ID Birth Certificate US Passport Marriage License Unexpired Foreign Passport (VISA) Permanent Resident Card Test Attempt: 1 st 2 nd 3 rd Score: PASS FAIL I certify that the applicant has successfully completed Ground Vehicle Operating Regulation Test: 32 SIDA Training I certify that the applicant has received training as specified in the Airport Security Program in accordance with TSAR Part 1542.213(b), on rules and regulations for access to the airport s SIDA. I also certify that this applicant has satisfactorily completed SIDA Training on this date. 33 Fingerprinting Name of CDA Official collecting prints: Prints Taken 4/1/2018 3
Chicago Airport System Fingerprint Application My signature below certifies that I have not been convicted (or found not guilty by reason of insanity), in the last ten years of any of the disqualifying crimes listed below. I understand and acknowledge that once I have been given authorization for unescorted access to the SIDA or Sterile Area, and/or the authority to authorize others to have access privileges, I must inform the ID Badging Office and surrender my SIDA or Sterile Area ID within 24 hours of being convicted or found not guilty by reason of insanity for any of the disqualifying crimes listed below. In addition, should my FBI fingerprint-based Criminal History Records Check (CHRC) disclose disqualifying information and I have questions about my results or request a copy of them, I must write to the Airport Security Coordinator at O Hare International Airport, Department of Aviation Security Division, PO Box 66142, Chicago, IL 60666. 1. Forgery of certificates, false marking of aircraft and other aircraft registration violation 2. Interference with air navigation 3. Improper transportation of hazardous materials 4. Aircraft piracy 5. Interference with flight crew members or flight attendants 6. Commission of certain crimes aboard aircraft in flight 7. Carrying a weapon or explosive aboard aircraft 8. Conveying false information and threats 9. Aircraft piracy outside the special aircraft jurisdiction of the United States of America 10. Lighting violations involving transporting controlled substances 11. Unlawful entry into an aircraft or airport area that serves air carriers or foreign air carriers contrary to established security requirements 12. Destruction of an aircraft or aircraft facility 13. Murder 14. Assault with intent to murder 15. Espionage 16. Sedition 17. Kidnapping or hostage taking 18. Treason 19. Rape or aggravated sexual abuse 20. Unlawful possession, use, sale, distribution or manufacture of an explosive or weapon 21. Extortion 22. Armed or felony unarmed robbery 23. Distribution of, or intent to distribute a controlled substance 24. Felony arson 25. Felony involving bribery 26. Felony involving a threat 27. Felony involving willful destruction of property 28. Felony involving importation or manufacture of a controlled substance 29. Felony involving burglary 30. Felony involving theft 31. Felony involving dishonesty, fraud or misrepresentation 32. Felony involving possession or distribution of stolen property 33. Felony involving aggravated assault 34. Illegal possession of a controlled substance punishable by a maximum term of imprisonment of more than 1 year 35. Violence at international airports 36. Conspiracy or attempt to commit any of the aforementioned criminal acts X Applicant s Signature 4/1/2018 4
FAR Part 139.303/329 Training Application Step 5 1 Company Name: Company Code: 2 Applicant Name 3 Company Type AIRLINE or CONCESSIONS CONSTRUCTION GOVERNMENT SUB- VENDOR CONTRACTOR 4 Driver BASIC ADVANCED TAXI 5 Training Not Required Annual Required Biennial Required Annual 303 To be completed only if training is required 6 Specific Training Type Advanced Driver Aircraft Repositioning Biennial AOA Training 7 Job Title Employer Certification The training selected above is based on your answers provided in the badging application. All five pages of the badging application must be presented upon completion to start the badging process. 8 As Signatory I certify that the applicant meets the criteria to be designated as essential to the operation of the employer. X Print Name Badge# Telephone Number: FOR CDA USE ONLY X Training Instructor Signature: Authorization Seal This Form Expires on: 4/1/2018 5