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 |
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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: |
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IAC/CCSF Name |
IAC/CCSF Number |
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Physical City |
State |
Start Date |
End Date |
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IAC/CCSF Name |
IAC/CCSF Number |
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Physical City |
State |
Start Date |
End Date |
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Section 2. Previously Certified, but Revoked |
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I certify that as a proprietor, general partner, officer, director, or owner, I have had my certification revoked |
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IAC Number |
Physical City, State |
Date Revoked |
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My certification was revoked for the following reason
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Section 3. Not Previously Certified |
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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. |
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Section 4. Signature |
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Applicant Signature and Date |
Page
TSA Form 419D, [Month] [Year] [File: #] OMB control number [# - #]; Expiration Date: [mm/dd/yyyy]
File Type | application/msword |
Author | Craig Henry |
Last Modified By | joanna.johnson |
File Modified | 2010-02-25 |
File Created | 2010-02-25 |