Form TSA Form 2212 TSA Form 2212 Transportation Worker Identification Credential (TWIC) D

Transportation Worker Identification Credential (TWIC) Disclosure Form

and Certifications

The Transportation Security Administration (TSA), in coordination with the United States Coast Guard, developed the Transportation Worker Identification Credential (TWIC) Program in response to the Maritime Transportation Security Act of 2002 (MTSA). MTSA requires a biometric identification credential for individuals who require unescorted access to secure areas of maritime facilities and vessels. Before issuing a TWIC, TSA must conduct a security threat assessment on the TWIC applicant. An applicant who, as a result of the assessment, is determined to not pose a security threat, will be issued a TWIC.

Each applicant for a TWIC must provide biographic information, identity documents, biometric information including fingerprints and a digital photograph, and pay the established TWIC fee. TSA will send pertinent parts of the enrollment record to the FBI, as well as within the Department of Homeland Security (DHS), so that appropriate terrorist threat, criminal history, and immigration checks can be performed. TSA will review the results of the checks to determine if the person poses a security threat, and will notify the applicant of the results. When TSA determines that an applicant qualifies to receive a TWIC, a credential will be produced and sent to the enrollment center at which the applicant applied. The applicant will return to the enrollment center for issuance and activation of the TWIC. Possession of a TWIC does not guarantee access to secure areas because the owner/operator controls which individuals are granted unescorted access to the facility or vessel. Rather, TWIC is a secure, verified credential that can be used in conjunction with the owner/operator’s risk-based security program that is required in security regulations issued by the Coast Guard.

Privacy Act Notice: Authority: The authority for collecting this information is 49 U.S.C.114, 40113, and 5103a. Purpose: This information is needed to verify your identity and to conduct a security threat assessment to evaluate your suitability for a Transportation Worker Identification Credential. Furnishing this information, including your SSN or alien registration number, is voluntary; however, failure to provide it will delay and may prevent completion of your security threat assessment. Routine Uses: Routine uses of this information include disclosure to the FBI to retrieve your criminal history record; to TSA contractors or other agents who are providing services relating to the security threat assessments; to appropriate governmental agencies for licensing, law enforcement, or security purposes; or in the interests of national security; and to foreign and international governmental authorities in accordance with law and international agreement.

PAPERWORK REDUCTION ACT STATEMENT:  Statement of Public Burden:  TSA is collecting this information to determine your eligibility for a TWIC.  This is a voluntary collection of information but failure to provide the information may result in an inability to approve your eligibility for a TWIC.  TSA estimates that the total average burden per response associated with this collection for enrollment is approximately 90 minutes.  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-NEW, which expires dd/mm/yyyy.

Certifications -- (Initial each of the items below)

________ 1. As part of my employment duties, I am required to have unescorted access to secure areas of maritime facilities or vessels in which a Transportation Worker Identification Credential is required; or, I am now, or I am applying to be, a credentialed merchant mariner; or I am a commercial driver licensed in Canada or Mexico transporting hazardous materials in accordance with 40 CFR 1572.201.

________ 2. I acknowledge that if TSA determines that I pose a security threat, my employer, as listed on this application, may be notified. If TSA or other law enforcement agency becomes aware of an imminent threat to a maritime facility or vessel, TSA may provide limited information necessary to reduce the risk of injury or damage to the facility or vessel.

_______ 3. You must answer each of the following questions by checking with either the “Yes” or “No” box. If your answer indicates that you intend to request a waiver, the waiver process will not begin until you receive an Initial Determination of Threat Assessment (IDTA). Complete instructions on how to file a waiver request will be provided with the IDTA. If you request it, the Trusted Agent will provide a copy of the applicable TWIC rule sections that are mentioned in the questions and define the disqualifying offenses.

Printed Name of TWIC Applicant

Signature of TWIC Applicant Date

The information I have provided on this application 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, or an omission of a material fact on this application, can be punished by fine or imprisonment or both (see 18 U.S.C. 1001), and may be grounds for denial of a Transportation Worker Identification Credential.

I certify that I assisted in the completion of this form at the request of the applicant named on this TWIC enrollment document, that the responses provided are based on all information of which I have knowledge, or which were provided to me by the applicant, and that the completed enrollment form has been read to the applicant in the language the applicant speaks fluently for verification before he or she signed the application in my presence. I understand that a knowing and willful false statement or an omission of a material fact on this enrollment document can be punished by fine or imprisonment or both, and may be grounds for denial of a TWIC.

Printed Name Helper/Translator

Signature Date

Daytime Telephone

Address

TSA Form 2212, March 2007 OMB 1652-NEW, which expires dd/mm/yyyy