Form TSA Form Number 41 TSA Form Number 41 Security Threat Assessment Applicaton

Air Cargo Security Requirements

TSA Form 419F_STA Application

Security Threat Assessment (STA)

OMB: 1652-0040

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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.

Page 1 of 3
PAPERWORK REDUCTION ACT BURDEN STATEMENT: TSA is collecting this information to qualify entities as Certified Cargo
Screening Facilities. The public burden for this collection of information is estimated to be approximately 15 minutes. This is a mandatory
collection of information. Send comments regarding this burden estimate or any other aspect of this collection to: TSA-11, Attention: PRA 16520040 601 South 12th Street, Arlington, VA 22202. An agency may not conduct or sponsor, and persons are not required to respond to, a collection
of information unless it displays a currently valid OMB control number. The OMB control number assigned to this collection is 1652-0040, which
expires 08/31/2009.

TSA Form 419F

OMB control number 1652-0040; Expiration Date: 08/31/2009

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

IAC Principal Title (if IAC Principal)

Section 3. Applicant Information
Social Security Number (optional)

Name (First, Middle, Last)

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

@
Email Address

Country of
Citizenship

Male
Gender

Female

/
/
Date of Birth

Place of Birth (City, State,
Country

Alien Registration
Number (If Applicable)

Naturalization Date (If
Naturalization Certificate Number (If
Applicable)
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

Current Residential address:
Street Address

Start Date

State

Zip Code

CURRENT
End Date of Residency

Page 2 of 3
PAPERWORK REDUCTION ACT BURDEN STATEMENT: TSA is collecting this information to qualify entities as Certified Cargo
Screening Facilities. The public burden for this collection of information is estimated to be approximately 15 minutes. This is a mandatory
collection of information. Send comments regarding this burden estimate or any other aspect of this collection to: TSA-11, Attention: PRA 1652XXXX 601 South 12th Street, Arlington, VA 22202. An agency may not conduct or sponsor, and persons are not required to respond to, a
collection of information unless it displays a currently valid OMB control number. The OMB control number assigned to this collection is 1652XXXX, which expires dd/mm/yyyy.

TSA Form 419F, [mm/yy] [File: #]

OMB control number [# - #]; Expiration Date: [mm/dd/yyyy]

City:

State:

Zip Code: