Form TSA 2212 TSA 2212 TWIC Disclosure Form

TWIC 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 eligibility as part of enrollment. Completed forms must be submitted in person at the beginning of the enrollment process. If you are initially deemed ineligible, you will receive a “Preliminary Determination of Ineligibility” letter. You may then be eligible to appeal or apply for a waiver. If you apply for an appeal, you have the opportunity to provide documentation to TSA that corrects incomplete or incorrect information. If you apply for a waiver, you have the opportunity to provide additional information/documentation to TSA in support of your eligibility. [Note: if you are currently under indictment or have open felony charges, it is recommended that you wait to apply for a TWIC until the matter is resolved.]

SECTION I – DISCLOSURE
Part A. Acknowledgments – Review each statement and respond by checking Yes or No, as appropriate.
I am:  required to have unescorted access to secure areas of maritime facilities or vessels in which a TWIC is required; or applying to be a credentialed merchant mariner; or a commercial driver licensed in Canada or Mexico transporting hazardous materials in accordance with 49 CFR 1572.201; or authorized by TSA to complete the TWIC security threat assessment and/or apply for a TWIC.			Yes No
I understand that if I plan on applying for or renewing a Coast Guard (CG)-issued merchant 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 Examination Center to provide this information before my application for the CG-issued credential will be considered complete.			Yes No
I acknowledge that if the Transportation Security Administration (TSA) or another law enforcement agency determines that I pose a security threat, my employer may be notified of this information.  As such, TSA may provide limited information necessary to reduce the risk of injury or damage to any affected area or facility.			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 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: (check the box that applies)
a U.S. Citizen or U.S. National; or
not a U.S. Citizen or U.S. National, but fall into a category listed on page 3 and am eligible for a TWIC.
I currently hold a TWIC.			Yes No
I understand that when I pick up my renewal/replacement TWIC, I am responsible for turning in my previous TWIC.			Yes No
Part B. Criminal History – Review each statement and respond by checking Yes or No, as appropriate. (Please refer to page 4)
At any time in my life (excluding juvenile cases unless convicted as an adult), I was convicted or pled guilty (including “no contest”/nolo contendere) 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. 2332b(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”/nolo contendere), 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, receipt, transfer, shipping, transporting, import, export, storage of, or dealing in an explosive or explosive device. An explosive or explosive device includes, but is not limited to, 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 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; 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”/nolo contendere), 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, 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 (except welfare fraud and passing bad checks); 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 secure seaport areas; 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
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
I am wanted, under indictment or have an open criminal complaint/criminal information in a civilian or military court for a felony listed in Parts B1 through B3.			Yes No
Note: If you answered “Yes” to any of the statements listed in Parts B2 through B4, you are eligible to request a waiver and may still be issued a TWIC. If you answered “Yes” to Part B5 because you are currently under indictment or have open criminal charges, you should consider waiting to apply for a TWIC until these matters are resolved as enrollment fees are not refunded.
If initially denied for a TWIC, I plan on applying for a waiver.			Yes No
I understand that I must return my TWIC to the address provided on the credential if I: am currently, or become, 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, a 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. Printed Name of TWIC Applicant		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.
Signature of TWIC Applicant Date Daytime Telephone Email Address		Printed Name of Helper/Translator Signature of Helper/Translator Date Daytime Telephone

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, all information provided during the enrollment process assists in the timely processing of your application. 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: 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 73 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 10/31/2012.

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 (LPR) of the U.S. Refugee admitted under 8 U.S.C. 1157. Alien granted asylum under 8 U.S.C. 1158. Citizen of Micronesia, Marshall Islands, or Palau. Commercial driver who is a citizen of and licensed in Canada or Mexico to transport hazardous materials or admitted to U.S. to conduct business under 8 CFR 214.2(b)(4)(i)(E). Alien in valid F-1 non-immigrant status enrolled at the U.S. Merchant Marine Academy or comparable State maritime academy and sponsored by the U.S. Maritime Administration (MARAD). Alien in valid J-1 non-immigrant status enrolled at the U.S. Merchant Marine Academy or comparable State maritime academy and sponsored by MARAD. Alien in valid M-1 non-immigrant status enrolled at the U.S. Merchant Marine Academy or comparable State maritime academy. Alien in valid R-1 (Religious Workers) status sponsored by MARAD. Alien in a lawful nonimmigrant status with unrestricted authorization to work in the U.S. holding one of the following visas: A-1: Principal alien and immediate family members of an Ambassador, Public Minister, Career Diplomat, Consular Officer, Head of State, with a bilateral agreement in place; A-2: Principal alien and immediate family members of other foreign government officials or employees coming to the United States, including technical and support staff of A-1, with a bilateral agreement in place; A-13 or A-14: Family unity; E-1: Spouse and dependent children of an treaty trader; E-2: Spouse of a treaty investor or employee of a treaty investor spouse; G-1: Principal alien and immediate family member of a principal resident representative of recognized foreign member government to international organization and staff, with a bilateral agreement in place; G-3: Principal alien and immediate family member of a representative of a non-recognized or nonmember foreign government to international organization, with a bilateral agreement in place; G-4: Principal alien and immediate family member of an International organization officer or employee with a bilateral agreement; J-2: Spouse or minor child of exchange visitor; K-3: Spouse of U.S. Citizen (under LIFE Act provisions); K-4: Child of K-3; L-2: Spouse or child of L-1; 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”; Principal alien and immediate family members of North Atlantic Treaty Organization (NATO) officials and representatives with bilateral agreement in place: NATO-1, NATO-2, NATO-3, NATO-4, NATO-5, NATO-6; S-7: Spouse, unmarried sons and daughters, and parents of witness or informant;

T-1: Victim of a severe form of trafficking in persons; T-2: Spouse of 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 is under 21 years of age); T-5: Unmarried sibling under age of 18 of a T-1 under age of 21; TPS: Temporary protected status (TPS); U-1: Victim of certain criminal activity; U-2: Spouse of U-1; U-3: Child of U-1; U-4: Parent of U-1 (if U-1 is under 21 years of age); U-5: Unmarried sibling under age 18 of a U-1 under age 21; V-1: Spouse of an LPR who is the principal beneficiary of a family-based petition which was filed prior to December 21, 2000, and has been pending for at least 3 years; V-2: Child of an LPR who is the principal beneficiary of a family-based visa petition that was filed prior to December 21, 2000, and has been pending for at least 3 years; OR V-3: The derivative child of a V-1 or V-2. Alien with restricted authorization to work in the U.S. holding one of the following visas: B1-OCS: Business visitor/outer continental shelf (OCS); B-1 or B-1/B-2 with ‘TWIC Letter Received’ annotation: Business visitor requiring a TWIC; BBBCV: B-1/B-2 and Border Crossing Card (Mexicans only); C-1/D: Combined transit and crewman visa; E-1 (Principal): Treaty trader or employee of treaty trader; E-2 (Principal): Treaty investor, or employee of treaty investor; E-3: Australian nationals working in specialty occupations, including spouse; E-3 D: Spouse or child of E-3; E-3R: Returning National of Australia who are professionals coming to the U.S. to perform services in a specialty occupation to uninterrupted employment; H-1B: Specialty occupations; H1-B1: Specialty occupations (professional) (Citizens of Chile or Singapore only) L-1: Intracompany transferees; L-1A: Executive, managerial (intracompany transferee); L-1B: Specialized knowledge professionals; O-1: Extraordinary ability; O-1A: Extraordinary ability in sciences, arts, education, business, or athletics; O-1B: Extraordinary achievement in motion picture and/or television productions; OR TN: Trade visas for Canadian and Mexican business persons seeking to engage in professional activities under the North American Free Trade Agreement (NAFTA). NOTE: The following visa types with unrestricted work authorization are not permitted to obtain a TWIC: K-1: Fiancé or fiancée of U.S. citizen; K-2: Minor child of K-1. S-5: Informant of criminal organization information; OR S-6: Informant of terrorism information.

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 secure seaport areas 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.

Previous editions of this form are obsolete.

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TSA Form 2212, July 2012 OMB 1652-0047, which expires 10/31/2012