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

Certified Cargo Screening Program

TSA_Form_419G_Validation_Firms_Application

Validation Firm Applications

OMB: 1652-0053

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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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TSA Form [#], [Month] [Year]

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

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