Phone Assisted Pre-Enrollment

PRA ICR -TSA Pre✓™ Application Program - InPerson Workstation as of 2013-11-22

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PRA ICR -TSA Pre✓™ Application Program - InPerson Workstation as of 2013-11-22

Universal Enrollmentervices
Privacy Act and Paperwork Reduction Act Statements
PRIVACY ACT STATEMENT:
Authority: The authority for collecting this information is 49 U.S.C. 114 and 114note.
Principal Purpose(s):
This information is needed to verify your identity and to conduct a security threat assessment to evaluate your eligibility for the TSA Pre3 application
program. 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 security threat assessment. Failure to provide it will delay and may prevent completion of your security threat assessment.
Routine Use(s): Principal disclosures 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; and to appropriate governmental agencies for licensing, law enforcement, or security purposes, or in
the interests of national security. For additional information regarding disclosures, please see system of records notice DHS/TSA-021, TSA Pre3™ Application Program

PAPERWORK REDUCTION ACT STATEMENT: Statement of Public Burden: This is a voluntary collection of information, but failure to provide the information
may result in an inability to approve your eligibility for the requested TSA program or benefit. TSA estimates that the total average burden per response
associated with this collection for enrollment is approximately 9-12 minutes, not including travel or wait time. 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 for this collection is OMB TBD.

Service

Identity

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PRA ICR -TSA Pre✓™ Application Program - InPerson Workstation as of 2013-11-22

At this time, only U.S. Citizens, U.S. Nationals and Lawful Permanent Residents (LPR) of the U.S. are eligible for the TSA Pre™ application program.

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PRA ICR -TSA Pre✓™ Application Program - InPerson Workstation as of 2013-11-22

Prove Identity

TSA Pre3™

Determine Documents
Documents

Additional Documents

Transportation Worker Identification Credential (TWIC)
Driver’s license issued by a State or outlying possession of the U.S.
Enhanced Tribal Card (ETC)
Free And Secure Trade (FAST) Card
ID card issued by a State or outlying possession of the U.S.
U.S. Passport Book or Passport Card
Merchant Mariner Credential (MMC)
Merchant Mariner Document (MMD)
Merchant Mariner License (MML) with official seal or certified copy
NEXUS Card
U.S. Passport (book or card)
Secure Electronic Network for Travelers Rapid Inspection (SENTRI)
United States Enhanced Driver’s License (EDL)
Consular Report of Birth Abroad (FS-240)
Certification of Report of Birth Abroad (DS-1350 OR fs-545)
Department of Transportation (DOT) medical card
Expired U. S. passport (within 12 months of expiration)
Native American tribal document (with photo)
Original or certified copy of birth certificate issued by a state, county,

Back

Identity

Fee

Payment

-AND-

Biographics

Required Identity Documents:
U.S. Passport Book or Passport Card

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PRA ICR -TSA Pre✓™ Application Program - InPerson Workstation as of 2013-11-22

Universal
Enrollment Services
Prove Identity

TSA Pre3™

Accepted
*Document Number:

100003106
*Issuance Date:

*Expiration Date:

11/25/2005

11/24/2015

November 25, 2005

November 24, 2015

Comment:

Flatbed Scan

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PRA ICR -TSA Pre✓™ Application Program - InPerson Workstation as of 2013-11-22

Universal
Enrollment
Services
Collect Payment
y

TSA Pre3™

Choose Payment Method

Credit Card

Check

NonRefundable
$mount Due $85.00

Money Order

Swipe Card
We Accept

* Name on Card

John Smith
* Credit Card Number

4444657591231475
* Expiration Date

08

/

14

* CSC

152

Charge
ge

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Identity

Fee

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PRA ICR -TSA Pre✓™ Application Program - InPerson Workstation as of 2013-11-22

Universal
Enrollment
Services
y
Collect Payment

TSA Pre3™

Choose Payment Method

Credit Card

Check

Amount Due $85.00

Money Order

Swipe Card
We Accept

Credit Card ending in 5012
was successfully charged

$85.00

* Name on Card

John Smith
* Credit Card Number

4444657591231475
* Expiration Date

08

/

14

* CSC

152

Charge

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Identity

Fee

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PRA ICR -TSA Pre✓™ Application Program - InPerson Workstation as of 2013-11-22

TSA Pre™

NonRefundable Amount Due: $85.00

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PRA ICR -TSA Pre✓™ Application Program - InPerson Workstation as of 2013-11-22

TSA Pre™
NonRefundable Amount Due: $85.00

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PRA ICR -TSA Pre✓™ Application Program - InPerson Workstation as of 2013-11-22

Universal
Services
Capture Enrollment
Biographics

TSA Pre3™

Answer Personal Questions
* 1. Have you ever used a maiden/previous name?

Yes

No

* 2. Have you ever used an alias?

Yes

No

* 3. Is your mailing address the same as your residential address?

Yes

No

* 4. Have you lived at your current residential address for more than five (5) years?

Yes

No

Key Pad Functions

1 = Yes

Back

2 = No

7 = Move back to previous question

Identity

Fee

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PRA ICR -TSA Pre✓™ Application Program - InPerson Workstation as of 2013-11-22

Universal
Services
Capture Enrollment
Biographics

TSA Pre3™

Enter Personal Information
First Name

Middle Name

Last Name

John

Steven

Smith

Suffix

* Middle Name

* Last Name

Jimmy

NMN

John

* Alias
* First Name

* Middle Name

* Last Name

Jimmy

Hunter

John

6

ft

2

* Weight

in

12/30/1972

Male

205

lbs

Suffix

Suffix

* Hair Color

* Eye Color

Brown

Multi-color

Social Security Number

Social Security Number

*********

Back

Gender

December 30, 1972

* Maiden/Previous Name
* First Name

US
Metric
Height
*

Date of Birth

111-08-5114

Identity

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PRA ICR -TSA Pre✓™ Application Program - InPerson Workstation as of 2013-11-22

Universal
Services
Capture Enrollment
Biographics

TSA Pre3™

Enter Residential Address
* Country

United States
* Address Line 1

123 Elm Hill Pike
Address Line 2

* City

* State/Province

* Postal Code

Nashville

Tennessee

37214 - 0129

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PRA ICR -TSA Pre✓™ Application Program - InPerson Workstation as of 2013-11-22

Universal
Services
Capture Enrollment
Fingerprints

TSA Pre3™
Place Fingers on Device

3
2

4
5

Identity

Fee

Payment

Biographics

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PRA ICR -TSA Pre✓™ Application Program - InPerson Workstation as of 2013-11-22

Universal
Services
Capture Enrollment
Fingerprints

TSA Pre3™
Accepted

3
2

4

3

4

5

2

5

Right Fingers

Rescan

Identity

Fee

Payment

Biographics

Fingerprints

Disclosure

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PRA ICR -TSA Pre✓™ Application Program - InPerson Workstation as of 2013-11-22

Universal
Services
Capture Enrollment
Fingerprints

TSA Pre3™
Place Thumbs on Device

6

1

Identity

Fee

Payment

Biographics

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PRA ICR -TSA Pre✓™ Application Program - InPerson Workstation as of 2013-11-22

Universal
Services
Capture Enrollment
Fingerprints

TSA Pre3™
Accepted

6

1

6

1

Rescan

Identity

Fee

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PRA ICR -TSA Pre✓™ Application Program - InPerson Workstation as of 2013-11-22

Universal
Services
Capture Enrollment
Fingerprints

TSA Pre3™
Place Fingers on Device

9

8
7

0

Identity

Fee

Payment

Biographics

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Disclosure

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PRA ICR -TSA Pre✓™ Application Program - InPerson Workstation as of 2013-11-22

Universal
Services
Capture Enrollment
Fingerprints

TSA Pre3™
Accepted

9

8
7

8

9

0

7

Right Fingers

Rescan

Identity

Fee

Payment

Biographics

Fingerprints

Disclosure

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PRA ICR -TSA Pre✓™ Application Program - InPerson Workstation as of 2013-11-22

Universal
Capture Enrollment
DisclosureServices

TSA Pre3™

Answer Questions
Note: If you answer ‘Yes’ to question 2,3, 4 or 6 you may want to reconsider applying. If you answer 'Yes' to question 5, because you are currently under
indictment or have open criminal charges, you should consider waiting to apply until these matters are resolved. Application enrollment fees are not refunded.
1. Are you a U.S. citizen or U.S. National?

Yes

No

2. Excluding juvenile cases unless convicted as an adult, have you been convicted, pled guilty including “no contest” (nolo contendere),
or found not guilty by reason of insanity, of any disqualifying felony listed in TSA Eligibility Requirements (Section VII) Part A, in any jurisdiction,
military or civilian?

Yes

No

3. Excluding juvenile cases unless convicted as an adult, have you been convicted, pled guilty including “no contest” (nolo contendere),
Yes
or found not guilty by reason of insanity, of any disqualifying felony listed iin TSA Eligibility Requirements (Section VII,) Part B, in any jurisdiction,
military or civilian, during the 7 years before the date of this application?

No

4. Have you been released from incarceration in any jurisdiction, military or civilian, for committing any disqualifying felony listed
in TSA Eligibility Requirements (Section VII) Part B, during the 5 years before the date of this application?

No

Yes

5. Are you wanted or under indictment for any disqualifying crime listed in TSA Eligibility Requirements (Section VII) Parts A and B?

Yes

6. Have you ever been found by a court or other lawful authority as lacking mental capacity or involuntarily committed to
a mental institution?

Yes

No
No

Key Pad Functions

1 = Yes

2 = No

7 = Move back to previous question

Identity

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PRA ICR -TSA Pre✓™ Application Program - InPerson Workstation as of 2013-11-22

Universal
Capture Enrollment
DisclosureServices

TSA Pre3™

Accepted
I understand my continuing obligation to notify TSA (at tsa.gov) within 24 hours if I am convicted or found not guilty by reason of insanity of any disqualifying crime, or
adjudicated as a mental defective or committed to a mental institution, while I am enrolled in the TSA Pre3™ Application Program.
The information I provided on this application is true, complete, and correct to the best of my knowledge and belief and is provided in good faith. I understand
that a knowing and willful false statement, or an omission of a material fact can be punished by fine or imprisonment or both (see section 1001 of Title 18 United
States Code), and may be grounds for denial of my application for the TSA Pre3™ Application Program by TSA.
Applicant Signature:

John S. Smith

Comment:

Translator used to interpret disclosure

Comment:

Scan

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PRA ICR -TSA Pre✓™ Application Program - InPerson Workstation as of 2013-11-22

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PRA ICR -TSA Pre✓™ Application Program - InPerson Workstation as of 2013-11-22

Universal
Enrollment Services
Submit Enrollment

TSA Pre3™

Summary

Applicant:

JOHN S. SMITH

KTN:

UNASSIGNED

UE ID:

U11F-193H9F

Service:

TSA PRE3™

Fee:

$85.00

Paid:

$85.00

Method:

Customer Support:
855-DHS-UES1
(855-347-8371)
Website:
universalenroll.dhs.gov

CARD (1475)

Auth Number:

123ABC

Date/Time:
07/16/2013 / 8:56 AM
Enrollment Location: Nashville, TN (8023)
Notification Method: 1-615-123-4567

Identity

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PRA ICR -TSA Pre✓™ Application Program - InPerson Workstation as of 2013-11-22

SECTION VII – TSA ELIGIBILITY REQUIREMENTS
Disqualifying Criminal Offenses
Part A: Permanent Disqualifying Criminal Offenses
A person will be disqualified if he or she was convicted or found not guilty by reason of insanity for any of the following
felonies:
a) Espionage or conspiracy to commit espionage
b) Sedition or conspiracy to commit sedition
c) Treason or conspiracy to commit treason
d) A federal crime of terrorism
e) A crime involving a TSI (transportation security incident). Note: 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. 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.
f) Improper transportation of a hazardous material under 49 U.S.C. 5124 or a comparable state law
g) Unlawful possession, use, sale, distribution, manufacture, purchase…or dealing in an explosive or explosive device
h) Murder
i) 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
j) Certain RICO (Racketeer influenced and Corrupt Organizations) Act violations where one of the predicate acts
consists of one of the permanently disqualifying crimes
k) Attempt to commit the crimes in items (a)-(d) of this section
l) Conspiracy or attempt to commit the crimes in items (e)-(j) of this section
Part B: Interim Disqualifying Criminal Offenses
A person will be disqualified if he or she was convicted or found not guilty by reason of insanity within the previous seven
years or was released from prison in the last five years for any of the following felonies:
a) Unlawful possession, use, sale, manufacture, purchase, distribution, receipt, transfer, shipping, transporting, delivery,
import, export of, or dealing in a firearm or other weapon
b) Extortion
c) Dishonesty, fraud, or misrepresentation, including identity fraud and money laundering, where the money laundering
is related to a crime listed in Parts A or B (except welfare fraud and passing bad checks)
d) Bribery
e) Smuggling
f) Immigration violations
g) Distribution, possession w/ intent to distribute, or importation of a controlled substance
h) Arson
i) Kidnapping or hostage taking
j) Rape or aggravated sexual abuse
k) Assault with intent to kill
l) Robbery
m) Fraudulent entry into a seaport
n) Lesser violations of the RICO (Racketeer Influenced
o) Conspiracy or attempt to commit crimes in this section
Part C: Under Want, Warrant or Indictment
A person will be disqualified if he or she is wanted or under indictment in any civilian or military jurisdiction for a felony
listed under Part A or Part B until the want or warrant is released or the indictment is dismissed.

Other Analyses

TSA may determine that an applicant is not eligible based on the additional analyses of the following:
a)
b)
c)

Interpol and other international information, as appropriate.
Terrorist watchlists and related information.
Any other information relevant to determining applicant eligibility or an applicant's identity.

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PRA ICR -TSA Pre✓™ Application Program - InPerson Workstation as of 2013-11-22

TSA may also determine that an applicant is not eligible if the search conducted under this part reveals extensive foreign
or domestic criminal convictions, a conviction for a serious crime not listed in 49 CFR 1572.103, or a period of foreign or
domestic imprisonment that exceeds 365 consecutive days.
Other information
In addition, TSA may determine that an applicant is not eligible based on analyses of other relevant information including
records related to violations of transportation security regulatory requirements. These include security-related offenses at
an airport, airport checkpoint, airport checked baggage area, other airport area, on board an aircraft, or in connection with
air cargo

Citizenship/Immigration Eligibility
Individuals must be U.S. citizens, U.S. nationals or lawful permanent residents (LPRs).

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