Form TSA Form 419H TSA Form 419H Aviation Security Known Shipper Verification

Air Cargo Security Requirements

TSA_Form_419H_ASKSV

Known Shippers--Web-based Entry

OMB: 1652-0040

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Aviation Security Known Shipper Verification



INSTRUCTIONS: Print clearly in all fields except for signatures. This form must be completed in its entirety by approved verification firms for the Known Shipper Program and email as a PDF to [email protected] or via fax to (703) 603-0725..


Section 1. Facility and Contact Data


Date of physical visit:      /     /     


Name of business visited:      


Also doing business as (trade name):      


Business type:      


Number of years in business:      


Employer’s Identifying Number:      


Name of individual contacted:      


Title:      

Section 2. Address Information


Physical address:      


City:      


State:      


Zip:      


Mailing address (if different):      


City:      


State:      


Zip:      

Section 3. Shipper’s Contact Information


Physical location phone number:      


Principal contact phone number:      


Emergency phone number:      


Fax number:      


Email address:      @     


Web address:      

Section 4. Verifier’s Information


Name & title of employee or authorized representative verifying the above information:      


Name of aircraft operator:      


Phone number:      


Email address:      


I certify the above information is true and correct and the onsite visit and verification was conducted in person as required by the TSA standard security program and applicable security directives. This certification is (i) made with the understanding that any intentional falsification may be subject to both civil and criminal penalties under 49 CFR 1540.103 and 18 U.S.C. 1001 and (ii) subject to record keeping requirements approved by TSA.


Signature of Verifier:


Signature of Shipper:


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TSA Form [#], [Month] [Year]

File Typeapplication/msword
AuthorCraig Henry
Last Modified Byjoanna.johnson
File Modified2010-02-25
File Created2010-02-25

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