TSA Form Number 41 CCSF Facility Profile Application

CCSF Facility Profile Application

INSTRUCTIONS: Companies seeking to be designated as a Certified Cargo Screening Facility (CCSF) must complete this form. A separate form must be submitted for each facility. This completed form must be submitted as part of the CCSF application package via fax to 703-603-0725 or via email as a protected data file (PDF) to [email protected]. Upon receipt of the complete CCSF application package, TSA will distribute the Certified Cargo Screening Program draft regulatory order, the Certified Cargo Screening Program Standard Security Program the Indirect Air Carrier Standard Security Program Alternate Procedures and the Facility Security Plan guidelines as applicable.

* 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 419E, Security Profile.

NOTE: Any fraudulent or false statements in conjunction with this application may be subjected to civil penalties under 49 CFR 1540.103(b) and fines and/or imprisonment of not more than 5 years under 18 U.S.C. 1001.

Section I: General Information

     

Facility Name

(     )     -     

(     )     -     

Telephone Number

Fax Number

     

Physical Address

     

     

     

     

City

State

Zip

Country or Territory

Complete the section below only if the mailing address of the facility is different from the physical address.

     

Address

     

     

     

     

City

State

Zip

Country or Territory

     

Company Name (if applicable)

(       )       -      

(       )       -      

     

Telephone Number (if applicable)

Fax Number (if applicable)

Indirect Air Carrier Number (if applicable)

Section II: Facility Details

Annual Volume Domestic (lbs)

     

Annual Volume International (lbs)

     

Annual Volume domestic (piece count)

     

Annual Volume International (piece count)

     

Annual volume (lbs) of cargo traveling on passenger aircraft (or tendered to a Freight Forwarder):

     

Annual volume (piece count- cargo) traveling on passenger aircraft (or tendered to a Freight Forwarder):

     

Breakdown (%) of volume (cargo) traveling within the US vs. International (if applicable):

     

Identify the closest airport to your facility (3 letter identifier)( i.e, IAD)

     

What are the primary commodities shipped by your facility? To better assist your organization during the certification process, please check all applicable boxes and provide a detailed summary of commodities shipped in the right hand column. With this information, our PCSAs can tailor their interaction appropriately based on commodity types shipped.

Electronics

Industrial Materials

Printed Matter

Perishables

Wearing Apparel

Pharmaceutical

Biological

Human Remains

Art

Media

Freight All Kinds (FAK)

Section III: Contact Information
Facility Contact – Primary
     		     		     
First Name		Last Name		Title
(       )       -      	(       )       -      		     
Primary Telephone Number	Secondary Telephone Number		Email Address
Facility Contact – Secondary
     		     		     
First Name		Last Name		Title
(       )       -      	(       )       -      		     
Primary Telephone Number	Secondary Telephone Number		Email Address
     
Secondary Email Address

.

TSA Form 419B, [mm/yy] [File: #] OMB control number 1652-0053 Expiration Date: 03/31/2010