Service Provider Application

TSA Registered Traveler

Service Provider Application

Company Name: _____________________________

TSA Service Provider Application

General Instructions:

1. Service Providers (SPs) requesting to participate in Registered Traveler (RT) shall complete the Service Provider Application Form in its entirety, and submit it and all required documentation electronically to [email protected]. SPs shall also mail the application form to TSA as indicated in Section 2.1.1 of the TSA Registered Traveler Service Provider Initial Participation Requirements and Application Process.

2. Sections I General Information, I Ownership Information, IV Security and VI Acknowledgement of Information must be completed in their entirety. Section III Foreign Ownership Status and Control is only to be completed by foreign-owned and/or operated companies. Section V Remarks is provided for additional space in answering the questions in Sections I and III.

3. Foreign-owned companies shall provide ownership information, percentage of ownership and relationships with their government and/or any acquisitions of U.S. companies.

4. TSA shall process a Criminal History Record Check (CHRC) and a Security Threat Assessment (STA) for each person listed in Section IV Security. Applicants shall provide the name and contact information of the company’s Security Officer. The Security Officer will be contacted and given instructions on how to submit the fingerprints of the persons listed in Section II of the RT application.

5. The application shall be signed by a management official with authority to sign official documents. After submitting an electronic application, applicants shall mail a hard copy application to TSA at the address listed on page 5 of this document.

PAPERWORK REDUCTION ACT STATEMENT OF PUBLIC BURDEN: Through this information collection, TSA is gathering information about your company to assess its qualifications to become a Service Provider for the TSA Registered Traveler program. This is a mandatory collection of information if you wish to participate as a Service Provider in the Registered Traveler program. TSA estimates that the total average burden per response associated with this collection is approximately twelve hours, which includes the time to compile and submit the information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The control number assigned to this collection is OMB 1652-0019, which expires 11/06.

Service Provider Application

SECTION I – GENERAL INFORMATION
Service Provider Information
1A. Service Provider Company Name		2. Taxpayer ID Number
1B. Service Provider Company Address		3. Type of Organization (Check one)
			A. Sole Proprietorship				F. Limited Liability Company
			B. General Partnership				G. Joint Venture
1C. City/State/Zip			C. Limited Partnership				H. Trust
			D. Corporation				Other (Specify Below):
			E. Subchapter S Corporation
4.Service Provider Point-of-Contact Information (name, phone and email address)
5. Trade Style Name (Provide a copy of filing)		6. Date Organization Established				7. State of Incorporation
8. Former Business Name (if applicable)		9. RT Product Type or Service Provided (Enrollment or Verification)
10. Are audited Financial Statements available? No Yes, indicate Name of Auditor and Date of most recent Audit opinion. Please attach a copy of the most recent audited Financial Statements.
11. If you check “YES” to any of the questions below, provide detailed information in Section V. Remarks
	YES			NO
11 A. Has the company or any of its affiliates ever filed for bankruptcy?
11 B. Does the company have any judgments, liens or pending suits?
11 C. Does the company have any contingent liabilities?
	YES			NO
11 D. Has the company or any of its affiliates disclosed business operations with outstanding debts?
11 E. Has the company ever had its business license revoked or suspended?
11 F. Has the company been denied participation in the RT program in the past? If so, when?
12. Names of affiliated Sponsoring Entities (if applicable):

Service Provider Application

SECTION II. OWNERSHIP INFORMATION
Note: If the parent company is owned and operated by a foreign entity, foreign-citizen, foreign government or national, provide further details in Section III. Foreign Ownership and Control.
1 A. Corporate Officers, Major Stockholders, Partners, or Other Owner’s Names		1 B. TITLE (If partner, state G(General) or L(Limited) in column)		1 C. % Ownership
		Actual Title	G or L
2. Parent Company Name (If applicable)
3. Address of Parent Company
4. City		5. State
6. Zip Code	7. Country	8. Phone Number

Service Provider Application

Section III. FOREIGN OWNERSHIP STATUS AND CONTROL
If you check “YES” to any of the questions below, provide detailed information in Section V. Remarks	Yes	No
1. Are there any non-U.S. interests involved in the company (control, shareholding/ownership, executives of a non-U.S. nationality, etc.)? If yes, please answer the following questions.
2. Does the company have any affiliation or business with any foreign government? If yes, please indicate the country and branch of the government and what type of affiliation exists or the types of services which are performed for the government entity?
3. What percentage of this company is foreign-owned and/or operated? _____________ %
4. Has the company performed work for the U.S. government before? If yes, please indicate which agencies below.
Agency Name	Contract Dates
5. Has this company acquired, merged, or joined with any U.S. companies? If yes, please indicate the company and dates of merger, acquisition or joint ventures.
U.S. Company Name	Dates of Merger/ Acquisition or Joint Venture

Service Provider Application

SECTION IV. SECURITY

Please provide the name and contact information of the company Security Officer

Name	Telephone Number	Email Address

Please provide the names and titles of the Officers/Principals/Directors with direct authority over RT program operations, RT program leadership and key Officers/Principals/Directors of primary subcontractors and/or business partners below.

Name

Title

Relationship

Service Provider Application

SECTION V. REMARKS

Please use this space to provide any additional information from Sections I-IV as necessary. Identify and group related remarks to the appropriate section. Additional sheets may be attached if needed.

Service Provider Application

SECTION VI. ACKNOWLEDGEMENT OF INFORMATION

I hereby acknowledge that the information indicated on this application is correct for the organization identified below. I understand that the Transportation Security Administration has the right to deny this application if it believes that the information is inaccurate or finds false statements herein.

Signature of Official: Date:

Title of Official:

Company Name:

For TSA Use Only

Date Application Received :

Initials: _________ Date: ___________________

1^st Level Review Complete:

Initials: _________ Date: ___________________

TSA Review Complete:

Initials: _________ Date: ___________________

Approved Not Approved

Decision:

Comments:

Company Name: _____________________

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