Form TSA Form Number 41 TSA Form Number 41 Security Threat Assessment Application

Security Threat Assessment Application

INSTRUCTIONS: Read and review the information below prior to completing this form. This form is for your reference. Please submit all information online through the STA Tool.

The CFRs are currently being written, so definitions for IACs apply in draft form for the CCSF STA Application

1. Unescorted Access to Cargo Definition

§ 1548.15 Access to Cargo: Security threat assessments for individuals having unescorted access to cargo.

This section applies to each indirect air carrier operating under this part.

(a) This section applies to each employee or agent the indirect air carrier authorizes to have unescorted access to cargo from the time-

(1) Cargo to be transported on an aircraft operated by an aircraft operator with a full all -cargo program under § 1544.101(h), or by a foreign air carrier under § 1546.101 (e), reaches an indirect air carrier facility where the indirect air carrier consolidates or holds the cargo until the indirect air carrier transfers the cargo to an aircraft operator or foreign air carrier, or

(2) Cargo to be transported on an aircraft operated by an a aircraft operator with a full program or by a foreign air carrier under

§ 1546.101(a) or (b), is accepted by the indirect air carrier.

(b) Before an indirect air carrier authorizes, and before an employee or agent gains, unescorted access to cargo as described in paragraph (a) of this section, each employee or agent must successfully complete one of the following:

(1) A criminal history records check under §§ 1542.209, 1544.229, or 1544.230 of this chapter, if the individual is otherwise required to undergo that check.

(2) A Security Threat Assessment under part 1540 subpart C of this chapter. An employee or agent who has successfully completed this

Security Threat Assessment for one employer need not complete it for another employer if the employee or agent has been continuously employed in a position that requires a Security Threat Assessment.

(3) Another Security Threat Assessment approved by TSA as comparable to paragraphs (1) or (2) of this section.

(c) Each indirect air carrier must ensure that each individual who has access to its cargo-

(1) Has successfully completed one of the checks in paragraph (b) of this section; (2) Is escorted by a person who has successfully completed one of the checks in paragraph (b) of this section; or (3) Is authorized to serve as law enforcement personnel by the airport operator associated with the location the person has unescorted access or by the Federal government.

(d) Operators must comply with the requirements of this section not later than [Insert date 180 days from date of publication in the Federal Register].

2. IAC Principal Definition -

§ 1548.16 Security threat assessments for each sole proprietor, general partner, officer, director, and certain owners of the entity. Each indirect air carrier, or applicant to be an indirect air carrier, must ensure that each sole proprietor, general partner, officer, director, and owner of the entity has successfully completed a Security Threat Assessment under part 1540 subpart C of this chapter. Each indirect air carrier must comply with the requirements of this section not later than [Insert date 180 days from date of publication in the Federal

Register

]. For purposes of

this section, the following terms are defined:

Owner means any person who, directly or indirectly--

(1) Owns, controls, or has power to vote 25 percent or more of any class of voting securities or other voting interests of an IAC or applicant to be an IAC; or

(2) Controls in any manner the election of a majority of the directors (or individuals exercising similar functions), or an IAC, or applicant to be an IAC.

(3) For purposes of this definition, members of the same family must be considered to be one person.

Same family means parents, spouses, children, siblings, uncles, aunts, grandparents, grandchildren, first cousins, stepchildren, stepsiblings, and parents-in-law, and spouses of any of the foregoing. (1) Each member of the same family, who has an ownership interest in an IAC, or applicant to be an IAC, must be identified if the family is an owner as a result of aggregating the ownership interests of the members of the family.

(2) In determining the ownership interests of the same family, any voting interest of any family member must be taken into account.

Voting securities or other voting interests means securities or other interests that entitle the holder to vote for or select directors (or individuals exercising similar functions).

3: Privacy Act and Paperwork Reduction Act Notices

Authority: The authority for collecting this information is 49 U.S.C. 114, 40113, and 49 U.S.C. 5103a.

Purpose: This information is needed to verify your identity and to conduct a Security Threat Assessment to evaluate your suitability for completing

the functions required by this position. Failure to furnish your SSN may result in delays in processing your application, but will not prevent

completion of your Security Threat Assessment. Furnishing the other information is also voluntary; however, failure to provide it may delay or

prevent the completion of your Security Threat Assessment, without which you may not be granted authorization to have unescorted access to air

cargo subject to TSA security requirements.

Routine Uses: Routine uses of this information include disclosure to TSA contractors or other agents who are providing services relating to the

Security Threat Assessments; to appropriate governmental agencies for 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. For further information, please consult DHS/TSA 002 Transportation Security Threat Assessment System.

Section 1. Current Employer Information

Employer Name:

     

Corporate Address

     

     

     

City

State

Zip Code

Section 2. Indirect Air Carrier Information

IAC Principal (if employed by an IAC, refer to page 2 of this form)

Yes

No

IAC Principal Title (if IAC Principal)      

Section 3. Applicant Information

     

     -     -     

Name (First, Middle, Last)

Social Security Number (optional)

     

Previous Name Used (First, Middle, Last) if applicable

     

Previous Name Used (First, Middle, Last) if applicable

     

Previous Name Used (First, Middle, Last) if applicable

     @     

Male

Female

     /     /     

Email Address

Gender

Date of Birth

Place of Birth (City, State, Country

     

     

     

     

Country of Citizenship

Alien Registration Number (If Applicable)

Naturalization Date (If Applicable)

Naturalization Certificate Number (If Applicable)

Section 4. Current Address and Previous Residency ( Please provide the last 5 years of residential address information (no PO Boxes)

Current Mailing Address:

     

     

     

     

Street Address

City

State

Zip Code

Current Residential address:

CURRENT

Street Address

Start Date

End Date of Residency

City:      

State:      

Zip Code:

     

Start Date:

     /     /     

Previous Residential Address (Street Address, City, State, Zip Code)

End Date:

     /     /     

     

Start Date:

     /     /     

Previous Residential Address (Street Address, City, State, Zip Code)

End Date:

     /     /     

     

Start Date:

     /     /     

Previous Residential Address (Street Address, City, State, Zip Code)

End Date:

     /     /     

     

Start Date:

     /     /     

Previous Residential Address (Street Address, City, State, Zip Code)

End Date:

     /     /     

     

Start Date:

     /     /     

Previous Residential Address (Street Address, City, State, Zip Code)

End Date:

     /     /     

TSA Form 419F, [mm/yy] [File: #] OMB control number 1652-0040 Expiration Date: 08/31/2009