Sensitive Security Information(When Completed)

SENSITIVE SECURITY INFORMATION(WHEN COMPLETED)

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 Badge Coordinator(BC)

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 mediaissued 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.

Badge Coordinator:

BC Printed Name ______Company ______

BC Signature ______Date ______Phone ______

For massport use only

Entered by ______Date ______Badge# ______

STA Approved ______Date ______

Issued Date ______by ______ExpirationDate ______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