Application for Public Side Identification
SENSITIVE SECURITY INFORMATION(WHEN COMPLETED)
Application for Public Side Identification
at Logan International Airport
Applicant’sLast Name: / First Name: / Middle Initial:
To Be Completed by Badge Coordinator (must be typed)
Applicant’s Primary Work Location (Check only one):
Terminals ABC E
General Aviation Full Access
Contractor Section:
Contract Begins / Contract Ends / Contract Number / Sponsoring Company’s Project Manager (Name)______
Sponsoring Company’s Project Manager (Signature)Date
Employer / Position
Name:
Last / First / Middle
Aliases or Nicknames: / Maiden Name:
Country of Birth / State of Birth / Country of Citizenship
Date of Birth: / *Social Security Number:
Work Phone: / Home/Cell Phone:
Home
Address
Street / City / State / Zip Code
Height: / Weight: / Sex: / Male / Female / Eye Color / Hair Color
Are you a U.S. Citizen? / No / Yes / If not, do you have:
Employment Authorization / No / Yes / OrResident Alien Card? / No / Yes
Employment
Authorization # / Expiration Date: / Resident Alien # / Expiration Date:
Do you have a valid driver’s license? / No / Yes
License # / State / Class / Restrictions
Have you ever been issued a Massport SIDA Badge and/or Public Side ID? / No / Yes
Badge #:
Two (2) forms of valid identification are required at time of badge issuance. See your sponsoring company for the list of acceptable ID’s.
*Furnishing this information is voluntary, however, if you do not provide your SSN or any other information requested, the Department of Homeland Security may be unable to complete a security threat assessment, without which the Authority will not issue identification media.
To Be Completed by Applicant
Applicant Certification
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).
Initial ______
I authorize the Social Security Administration to release my Social Security Number (SSN) and full name to the Transportation Security Administration, Office of Transportation Threat Assessment and Credentialing (TTAC), Attention: Aviation Programs (TSA-10)/Aviation Worker Program, 601 South 12th Street, Arlington, VA 20598.
Initial ______
I am the individual to whom the information applies and want this information released to verify 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.
Initial ______
Printed Full Name ______Date of Birth ______SSN ______
Applicant Signature ______Date ______
Privacy Act Notice
I hereby acknowledge that I have received a copy of the Privacy Act Notice from my sponsoring company. If my sponsoring company has not provided me with a copy I have requested it from the Massport Badging Office. I have read and fully understand the contents of the Privacy Act Notice.
Applicant Print Name______Date ______
Applicant Signature______
To Be Completed by Authorized Signatory (AS)
We agree to notify the Massport Airport Badging Office immediately if this employee is terminated, otherwise no longer has operational need for the identification media, laid off, or suspended, or if any identification media issued to employees of said company are lost, stolen, or otherwise “unaccounted for. We agree that upon termination or voluntary departure of this employee, identification mediawill be promptly returned to Massport’s Airport Badging Office. We also agree that, if they are not returned, said company will be subject to applicable fines in accordance with Massport’s Rules and Regulations.
Authorized Signatory:
Printed Name ______Company ______
Signature ______Date ______Phone ______
For massport use only
Entered by ______Date ______Badge # ______
STA Approved ______Date ______
Issued date ______by ______Expiration date ______PIN ______
WARNING: This record contains Sensitive Security 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 Administrator 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.
Revised: 11/08/2016