SECURITY BADGE UPDATE FORM

LAX SECURITY BADGE OFFICE

7333 WORLD WAY WEST, 1st FL

LOS ANGELES, CA 90045

(310) 646-0508

SECURITY BADGE OFFICE USE ONLY

SBO AGENT NAME / TRANSACTION DATE (MM/DD/YYYY)
/ /

TRANSACTION REQUESTED – FILL-IN THE CIRCLE FOR THE TRANSACTION TYPE REQUESTED

Badge Return Invalidate Badge Request Division Transfer / Change in Access
Request Post Access Change Update Contact Information

EMPLOYEE INFORMATION

Last Name (Applicant) / First Name / Middle Name / suffix
SECURITY Badge # / Social Security Number
- -

INVALIDATE BADGE

Invalidate Outstanding Badge (Badge Not Returned) / Date Reported to Badge Office: / / /
Describe reason for invalidation and efforts made to recover outstanding LAX Security Badge:
LAST KNOWN EMPLOYEE ADDRESS / LAST KNOWN EMPLOYEE CONTACT #
( ) -

REQUEST DIVISION TRANSFER & CHANGE IN ACCESS

OLD ORG / DIVISION CODE / JOB TITLE / REQUIRED ACCESS
.
NEW ORG / DIVISION CODE / JOB TITLE / REQUIRED ACCESS
.

REQUEST (LAX Drive-Thru) POST ACCESS CHANGE

Add LAX Drive-Thru Post Access / Remove LAX Drive-Thru Post Access

UPDATE (Employee) CONTACT INFORMATION

UPDATED EMPLOYEE ADDRESS / UPDATED EMPLOYEE CONTACT #
( ) -

COMPANY INFORMATION – FOR DIVISION TRANSFERS, THIS SECTION MUST BE COMPLETED BY AUTHORIZED SIGNER FOR NEW DIVISION

COMPANY NAME / DIVISION NAME / ORGANIZATION CODE
.
AUTHORIZED SIGNER NAME (PRINT) / CONTACT NUMBER / SIGNATORY ID NUMBER
( ) - / . .
AUTHORIZED SIGNATURE / DATE (MM/DD/YYYY)
x / / /

WARNING: This record contains Security Sensitive Information that is controlled under 49 CFR parts 15 and 1520. No part of this record may be disclosed to persons without a “need to know”, as defined in 49 CFR parts 15 and 1520, except with the written permission of the Transportation Security Administration or the Secretary of Transportation. Unauthorized release may result in civil penalty or other action. For U.S. government agencies, public disclosure is governed by 5 U.S.C. 552 and 49 CFR parts 15 and 1520. LAX Security Badge Update Form 1/2010