TSA Form Number 41 CCSF Principal Attestation

C CSF Principal Attestation

INSTRUCTIONS: This form is to be completed by any principal, proprietor, general partner, officer, director, or owner of a company seeking to be part of the Certified Screening Program. Please complete the applicable section and sign and date the form. This form must be submitted along with other parts of the CCSF application as a complete package via email as a PDF to [email protected] or via fax (703) 603-0725.

The complete CCSF application package includes TSA Form 419A, CCSF Letter of Intent, TSA Form 419B, CCSF Facility Profile Application, TSA Form 419C, CCSF SSI Agreement, TSA Form 419D Principal Attestation, TSA Form 419C Security Profile.

Section 1. Certification of Previously Approved Vendor
	I       certify that I have been a proprietor, general partner, officer, director, or owner (as defined in 49 CFR 1548.16) of an Indirect Air Carrier (IAC) or Certified Cargo Screening Facility (CCSF) listed below:
     				     
IAC/CCSF Name				IAC/CCSF Number
     		     	     /     /     		     /     /     
Physical City		State	Start Date		End Date
     				     
IAC/CCSF Name				IAC/CCSF Number
     		     	     /     /     		     /     /     
Physical City		State	Start Date		End Date
Section 2. Previously Certified, but Revoked
	I       certify that as a proprietor, general partner, officer, director, or owner, I have had my certification revoked
     		     				     
IAC Number		Physical City, State				Date Revoked
My certification was revoked for the following reason      
Section 3. Not Previously Certified
	I      certify that I have NOT previously been a proprietor, general partner, officer, director, or owner (as defined in 49 CFR 1548.16) of an IAC or CCSF.
Section 4. Signature
Applicant Signature and Date

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TSA Form 419D, [Month] [Year] [File: #] OMB control number [# - #]; Expiration Date: [mm/dd/yyyy]