Form TSA Form Number 41 TSA Form Number 41 TSA Approved Validation Firms Application

TSA Approved Validation Firms Application

INSTRUCTIONS: Companies seeking to be designated as TSA Approved Validation Firms must complete this form. This form must be submitted via fax at 703-603-0725 or emailed as a PDF to [email protected] along with a) signed letter of intent (including business/company profile), b) summary of qualification per the announcement to include a description of the facilities, resources, and personnel, the applicant has identified to conduct these assessments (i.e., explanation of previous experience, number of facility/security assessments/validations), in 500 words or less, c) legal documentation (i.e., articles of incorporation, legal LLC documents, sole proprietorship affidavit), d)principal attestation, e) TSA approved validation firms security coordinator government-issued photo ID, f) CCSF SSI Agreement, TSA Form 419C

Section 1. Company Information
Company Legal Name		     			Company Telephone #			     
Company Name, Doing Business As (if different)					     
Company Mailing Address		     				     			     	     
		Street Address				City			State	Zip Code
Company Physical Address (if different than mailing address):		     				     			     	     
		Street Address				City			State	Zip Code
Section 2. Company Identification Data
     				     			     
Federal Tax ID Number				Employer ID Number (EIN)			DUNS Number
Section 3. Company Security Coordinator Contact Information
Primary Point of Contact:			     		     			     
			Full Name		Email Address			Phone Number
Alternate Point of Contact			     		     			     
			Full Name		Email Address			Phone Number
Section 4. Company Acknowledgement
	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
	TSA approved validation firms will receive NO federal funding, but will be regulated by the Transportation Security Administration

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