TSA 2212 TWIC Disclosure and Certification

T WIC Disclosure and Certification

INSTRUCTIONS: If you must obtain a Transportation Worker Identification Credential (TWIC), you are required to undergo a security threat assessment. To undergo this assessment, all applicants must provide information requested below and the appropriate documentation to verify their identity and immigration status (if applicable) as part of the enrollment process. Completed forms must be submitted in person at the beginning of the enrollment process. If you are initially disqualified, you may be eligible for a TWIC and should apply for a waiver, which gives you the opportunity to provide additional information and documentation to support your eligibility. You must wait for an Initial Determination of Threat Assessment (IDTA) letter before applying for a waiver.

SECTION I – DISCLOSURE
Part A. Acknowledgments – Review each statement and respond by checking Yes or No, as appropriate.
As part of my employment duties, I am: or will most likely be required to have unescorted access to secure areas of maritime facilities or vessels in which a TWIC is required; currently or am applying to be a credentialed merchant mariner; or a commercial driver licensed in Canada or Mexico to transport hazardous materials					Yes No
I understand that if I plan on applying for or renewing a CG-issued mariner credential, but do not provide my Social Security Number and proof of citizenship during enrollment, I will be required to visit a CG Regional Exam Center to provide this information before my application for the CG-issued credential will be considered complete.					Yes No
I acknowledge that if TSA or other law enforcement agencies determine that I pose an imminent threat to national security or transportation security, my employer may be notified. TSA may provide limited information to the facility or vessel. Note: FBI rap sheets will not be shared with employers.					Yes No
I understand that since the TWIC will serve as a visual identification badge, items or attire should not obscure any part of my face when my photograph is taken. As a result, I acknowledge that: I will remove a hat or headgear unless worn daily for religious reasons. I will remove dark or non-prescription glasses with tinted lenses, unless they are required to be worn at all times for medical reasons. If so, a medical certificate may be required.					Yes No
I am:
a U.S. citizen or U.S. national.					Yes No
not a U.S. citizen or U.S. national, but fall into a category listed on page 3 that permits me to hold a TWIC.					Yes No
I am currently not a TWIC holder.					Yes No
Part B. Criminal History – Review each statement and respond by checking Yes or No, as appropriate. (Please refer to page 4 for more information)
At any time in my life (excluding juvenile cases unless convicted as an adult), I was convicted or pled guilty (including “no contest”) or found not guilty by reason of insanity in a civilian or military court of one or more of the following felonies:					Yes No
Espionage or conspiracy to commit espionage; Sedition or conspiracy to commit sedition;		Treason or conspiracy to commit treason; or A federal crime of terrorism as defined in 18 U.S.C. 2332(g) or a comparable State law.
Note: If you answer “Yes”, you are not eligible to receive a TWIC and/or a waiver.
At any time in my life (excluding juvenile cases unless convicted as an adult), I was convicted, pled guilty (including “no contest”), or found not guilty by reason of insanity in a civilian or military court of any of the following felonies:					Yes No
A crime involving a transportation security incident; Improper transportation of a hazardous material; Unlawful possession, use, sale, distribution, manufacture, purchase...or dealing in an explosive or explosive device; Murder;	Making a threat or maliciously conveying false information known to be false, concerning delivery, placement, or detonation of an explosive or other lethal device in a public, government, public transportation, or infrastructure facility; RICO Act violations where a predicate act is a crime listed in Parts B1 and B2; Attempt to commit a crime listed in Parts B1 and B2; or Conspiracy or attempt to commit a crime listed in Part B2.
Within the last 7 years, I was convicted, pled guilty (including “no contest”), or found not guilty by reason of insanity in a civilian or military court of any of the following felonies:					Yes No
Unlawful possession, use, sale, manufacture, purchase, distribution...or dealing in a firearm or other weapon; Extortion; Dishonesty, fraud, or misrepresentation, including identity fraud and money laundering (except welfare fraud and passing bad checks); Bribery; Smuggling; Immigration violations;			Distribution of, possession w/intent to distribute, or importation of a controlled substance; Arson; Kidnapping or hostage taking; Rape or aggravated sexual abuse; Assault with intent to kill; Robbery; Fraudulent entry into a seaport; RICO; or Conspiracy or attempt to commit the crimes listed in Part B3.
Within the last 5 years, I was released from prison following conviction for a felony listed in Part B3.					Yes No
I am wanted or under indictment in a civilian or military court for a felony listed in Parts B1 through B3.					Yes No
A civilian or military court has found me to lack mental capacity or I have been involuntarily committed to a mental health facility.					Yes No
Note: If you answered “Yes” to any of the crimes/felonies listed in Parts B2 through B6, you are eligible for a waiver and may still be issued a TWIC. If initially denied for a TWIC, do you plan to apply for a waiver?					Yes No
I understand that I must return my TWIC to the address provided on the credential if I: am wanted, under indictment for, convicted, or found not guilty by reason of insanity, of a felony listed in Parts B1 through B3; am found to be lacking mental capacity or involuntarily committed to a mental health facility; or no longer meet the immigration standards indicated by a “Yes” response in Part A5.					Yes No
SECTION II – CERTIFICATION
Please review and certify the responses provided in this form by printing and signing your name with a date. If help/translation assistance is provided, contact information for the helper/translator is required should follow up be necessary. For applicants and helpers/translators, knowing and willful false statement or an omission of a material fact in this form is punishable by fine or imprisonment or both (see 18 U.S.C. 1001), and may be grounds for denial of a TWIC.
Applicants: The information I have provided on this form is true, complete, and correct to the best of my knowledge and belief and is provided in good faith.				Helpers/Translators: I certify that I provided assistance in the completion of this form at the request of the named applicant; the responses provided are based on information of which I have knowledge or which was provided to me by the applicant; and I have read the completed form to the applicant in the language he/she speaks fluently for verification before he/she signed the application in my presence.
Printed Name of TWIC Applicant Signature of TWIC Applicant Date				Printed Name of Helper/Translator Signature of Helper/Translator Date Daytime Telephone Address Apt. # City, State, Zip

PRIVACY ACT STATEMENT: Authority: The authority for collecting this information is 49 U.S.C.114, 40113, and 5103a. Principal Purpose(s): This information is needed to verify your identity and to conduct a security threat assessment to evaluate your suitability for a TWIC. Furnishing this information, including your SSN or alien registration number, is voluntary; however, failure to provide it will delay and may prevent completion of your security threat assessment. For individuals who are mariners or applying to be one, the SSN is mandatory or they will be required to visit a Coast Guard Regional Exam Center to this information before an application is complete. Routine Use(s): Routine uses of this information include disclosure to the FBI to retrieve your criminal history record; to TSA contractors or other agents who are providing services relating to the security threat assessments; to appropriate governmental agencies for licensing, law enforcement, or security purposes; or in the interests of national security; and to foreign and international governmental authorities in accordance with law and international agreement.

PAPERWORK REDUCTION ACT STATEMENT: Statement of Public Burden:  TSA is collecting this information to determine your eligibility for a TWIC.  This is a voluntary collection of information but failure to provide the information may result in an inability to approve your eligibility for a TWIC.  TSA estimates that the total average burden per response associated with this collection for enrollment is approximately 90 minutes.  An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number.  The control number assigned to this collection is OMB 1652-0047, which expires 04/30/2008.

I am not a U.S. citizen or national, but fall into a category listed below which permits me to hold a TWIC

Lawful permanent resident of the U.S. Refugee admitted under 8 U.S.C. 1157. Alien granted asylum under 8 U.S.C. 1158. Alien in valid M-1 nonimmigrant status enrolled at the U.S. Merchant Marine Academy or a comparable State maritime academy. Citizen of Micronesia, Marshall Islands, or Palau. Alien with unrestricted authorization to work in the U.S. holding one of the following visas: A-1: Ambassadors, public ministers, career, diplomatic or consular officers, and members of their immediate family; dependent of principal alien may have unrestricted employment if appropriate bilateral agreement is in place; A-2: Other foreign government officials or employees, and members of their immediate family; dependent of principal alien may have unrestricted employment if appropriate bilateral agreement is in place; A-13: Family unity; G-1: Principal resident representative of recognized foreign member government to international organization, staff, and immediate family members; dependent of principal alien may have unrestricted employment if appropriate bilateral agreement is in place; G-3: Representative of non-recognized or nonmember foreign government to international organization and immediate family members; dependent of principal alien may have unrestricted employment if appropriate bilateral agreement is in place; G-4: International organization officer or employee and immediate family members; dependent of principal alien may have unrestricted employment if appropriate bilateral agreement is in place K-3: Spouse of U.S. Citizen (LIFE Act provisions); K-4: Child of K-3; N-8: Parent of alien classified SK-3 “Special Immigrant”; N-9: Child of N-8, SK-1, SK-2, or SK-4 “Special Immigrant”; NATO-1: Principal permanent representative of member state to NATO and resident members of official staff or immediate family; dependent of principal alien may have unrestricted employment if appropriate bilateral agreement is in place; NATO-2: Other representatives of member state; dependents of member of a force entering in accordance with the provisions of NATO Status-of-Forces agreement; members of such a force if issued visas; dependent of principal alien may have unrestricted employment if appropriate bilateral agreement is in place; NATO-3: Official clerical staff accompanying representative of member state to NATO or immediate family; dependent of principal alien may have unrestricted employment if appropriate bilateral agreement is in place;

NATO-4: Official of NATO other than those qualified as NATO-1 and immediate family; dependent of principal alien may have unrestricted employment if appropriate bilateral agreement is in place; NATO-5: Expert other than NATO officials qualified under NATO-4, employed on behalf of NATO and immediate family; dependent of principal alien may have unrestricted employment if appropriate bilateral agreement is in place; NATO-6: Member of civilian component who is either accompanying a Force entering in accordance with the provisions of the NATO Status-of-Forces agreement; attached to an Allied headquarters under the protocol on the Status of International Military headquarters set up pursuant to the North Atlantic Treaty; and their dependents; Dependent of principal alien may have unrestricted employment if appropriate bilateral agreement is in place; T-1: Victim of a severe form of trafficking in persons; T-2: Spouse of a victim of a severe form of trafficking in persons; T-3: Child of victim of a severe form of trafficking in persons; T-4: Parent of victim of a severe form of trafficking in persons (if T-1 victim is under 21 years of age); V-1: Spouse of an Lawful Permanent Resident Alien (LPR) who is the principal beneficiary of a family-based petition (Form I-130) which was filed prior to December 21, 2000, and has been pending for at least three years; V-2: Child of an LPR who is the principal beneficiary of a family-based visa petition (Form I-130) that was filed prior to December 21, 2000, and has been pending for at least three years; V-3: The derivative child of a V-1 or V-2; OR TPS: Temporary protected status. Commercial driver licensed in Canada or Mexico admitted to the U.S. to conduct business in the U.S. under 8 CFR 214.2(b)(4)(i)(E). Alien with restricted authorization to work in the U.S. holding one of the following visas: B1-OCS: Business Visitor/Outer Continental Shelf; C-1/D: Combined transit and crewman visa; E-1: Treaty trader; E-2: Treaty investor; E-3: Australian nationals working in specialty occupations; H-1B: Specialty occupation; H-1B1: Specialty occupation, entering under free trade agreements; L-1: Intracompany executive transfer; O-1: Extraordinary ability; OR TN: North American Free Trade Agreement (NAFTA). NOTE: The following visa types with unrestricted U.S. work authorization are not permitted to obtain a TWIC: S-5: Informant of criminal organization information; S-6: Informant of terrorism information; K-1: Fiancé or fiancée of U.S. Citizen; OR K-2: Minor child of K-1.

Disqualifying criminal offenses (49 C.F.R. 1572.103)

COLUMN A Conviction for one of the following felonies is disqualifying regardless of when it occurred, and the applicant is not eligible for a waiver. Espionage or conspiracy to commit espionage. Sedition, or conspiracy to commit sedition. Treason, or conspiracy to commit treason. A federal crime of terrorism as defined in 18 U.S.C. 2332b(g), or comparable State law, or conspiracy to commit such crime. Conviction for one of the following felonies is disqualifying regardless of when it occurred, and the applicant may apply for a waiver. A crime involving a transportation security incident. A transportation security incident is a security incident resulting in a significant loss of life, environmental damage, transportation system disruption, or economic disruption in a particular area, as defined in 46 U.S.C. 70101. The term “economic disruption” does not include a work stoppage or other employee-related action not related to terrorism and resulting from an employer-employee dispute. Improper transportation of a hazardous material under 49 U.S.C. 5124, or a State law that is comparable. Unlawful possession, use, sale, distribution, manufacture, purchase, receipt, transfer, shipping, transporting, import, export, storage of, or dealing in an explosive or explosive device. An explosive or explosive device includes an explosive or explosive material as defined in 18 U.S.C. 232(5), 841(c) through 841(f), and 844(j); and a destructive device, as defined in 18 U.S.C. 921(a)(4) and 26 U.S.C. 5845(f). Murder. Making any threat, or maliciously conveying false information knowing the same to be false, concerning the deliverance, placement, or detonation of an explosive or other lethal device in or against a place of public use, a state or government facility, a public transportations system, or an infrastructure facility. Violations of the Racketeer Influenced and Corrupt Organizations Act, 18 U.S.C. 1961, et seq., or a comparable State law, where one of the predicate acts found by a jury or admitted by the defendant, consists of one of the crimes listed in Column A. Attempt to commit the crimes in Column A, items 1 - 4. Conspiracy or attempt to commit the crimes in Column A, items 5 – 10.

COLUMN B Conviction for one of the following felonies is disqualifying if the applicant was convicted, pled guilty (including “no contest”), or found not guilty by reason of insanity within 7 years of the date of the TWIC application; OR if the applicant was released from prison after conviction within 5 years of the date of the application. The applicant may apply for a waiver. Unlawful possession, use, sale, manufacture, purchase, distribution, receipt, transfer, shipping, transporting, delivery, import, export of, or dealing in a firearm or other weapon. A firearm or other weapon includes, but is not limited to, firearms as defined in 18 U.S.C. 921(a)(3) or 26 U.S.C. 5 845(a), or items contained on the U.S. Munitions Import List at 27 CFR 447.21. Extortion. Dishonesty, fraud, or misrepresentation, including identity fraud and money laundering where the money laundering is related to a crime described in Columns A or B. Welfare fraud and passing bad checks do not constitute dishonesty, fraud, or misrepresentation for purposes of this paragraph. Bribery. Smuggling. Immigration violations. Distribution of, possession with intent to distribute, or importation of a controlled substance. Arson. Kidnapping or hostage taking. Rape or aggravated sexual abuse. Assault with intent to kill. Robbery. Fraudulent entry into a seaport as described in 18 U.S.C. 1036, or a comparable State law. Violations of the Racketeer Influenced and Corrupt Organizations Act, 18 U.S.C. 1961, et seq. , or a comparable State law, other than the violations listed in Column A, item 10. Conspiracy or attempt to commit felonies listed in Column B.

Page 4 of 4

TSA Form 2212, April 2008 rev. OMB 1652-0047, which expires 07/30/2011