TSA Form 419D CCSF Principal Attestation

Certified Cargo Screening Program

TSA_Form_419D_CCSF_Principal_Attestation

CCSF Applications

OMB: 1652-0053

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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My certification was revoked for the following reason      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]


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

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