In Person Enrollments with no Pre-Enrollment

Service Location: Nashville TN (8023)
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MI

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Smith

John

S

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Enroll

9:00am

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Joe

D

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Enroll

9:15am

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Steven

R

TWIC

Activate Card

9:30am

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Joanne

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TWIC

Enroll

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Clark

James

F

Pre

Enroll

10:30am

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George

S

Pre

Enroll

10:30am

Williams

Amy

A

TWIC

Enroll

10:45am

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Paul

R

TWIC

Reset Card PIN

11:00am

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Steve

H

TWIC

Enroll

11:30am

Anderson

Robert

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Pre

Enroll

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John

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Pre

Enroll

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Keith

W

TWIC

Reset Card PIN

12:30pm

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Chris

N

Pre

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Subject

Hoover

Richard

K

TWIC

Enroll

12:45pm
1:00pm

Service Outage

Lester

David

D

TWIC

Activate Card

1:30pm

Training Module Due

Freeman

Steven

S

TWIC

Enroll

1:45pm

Phone
*Date of Birth

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*
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United States (+1)
*Phone

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Message Center
Date

! 07/16/13
07/10/13

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EN 05/21/2014@ 8:56 AM

Service Location: Nashville TN (8023)
Search

Appointments

*Search Method

Last Name

Phone

New Customer

First Name

MI

Program

Appointment

Service

Walk-In

*Date of Birth

*Biometric

*
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United States (+1)
*Phone

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Clear

Message Center
Date

! 07/16/13
07/10/13

Subject

Service Outage
Training Module Due

Print Appointments

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EN 05/21/2014@ 8:56 AM

Service Location: Nashville TN (8023)
Enter Customer Information
Essential

Contact

*First Name

*Preferred Language

John

English

*Middle Name

*Method of Contact (At least one method is required)
Email
Verify Email

Steven

[email protected]
*Last Name

Smith
*Gender

Male
*Date of Birth

12/30/1972

Suffix

Country Code

United States (+1)
Country Code

United States (+1)

[email protected]
Phone 1

615-123-4567
Phone 2

615-123-7645

*Preferred Method of Contact

Email
December 30, 1972

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EN 05/21/2014@ 8:56 AM

Universal Enrollment Services
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EN 05/21/2014@ 8:56 AM

Universal Enrollment Services

TSA Pre/ ®

Important Notes
IMPORTANT!
1. Once payment has been submitted as part of your TSA Pre/ ® enrollment, NO REFUNDS will be provided, regardless of the eligibility assessment outcome.
2. You may not need to apply for the TSA Pre/ ® application program if you:
• Currently have a Known Traveler Number (KTN)
• Are a member of a DHS Trusted Traveler Program such as CBP Global Entry, NEXUS, or SENTRI
• Are a member of the U.S. military
• Are a civilian employee of the Department of Defense or U.S. Coast Guard
3. If you have a record of any crimes identified in the criminal disqualifiers list, you may not wish to apply for the TSA Pre/ ® application program, as NO
REFUNDS will be given for applicants who have been deemed ineligible.
4. TSA Pre/ ® lanes are available only at participating airports and with participating airlines.

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EN 05/21/2014@ 8:56 AM

Universal Enrollment Services

TSA Pre/ ®

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 Pre/ ®
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 Uses: 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 Pre/ ® 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 Control No. 1652-0059, which expires 05/31/2015.

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1

EN 05/21/2014@ 8:56 AM

Prove Identity

TSA Pre/ ®

Determine Citizenship
Note: At this time, only U.S. citizens, U.S. Nationals and lawful permanent residents (LPR) are eligible for the application.
*Country of Birth

United States
*City of Birth

*State/Province of Birth

Birmingham

Alabama

*Country of Citizenship

United States

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Iris

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1

EN 05/21/2014@ 8:56 AM

Prove Identity

TSA Pre/ ®

Determine Documents
Required Identity Documents

*Document

Birth Certificate bearing an official seal (or certified copy) issued by a state
Certify birth certificate as proof of citizenship (you are not required to have birth
certificate in your possession). $20 IdentoGO Birth Certificate Certification service
fee will be applied. This is an optional convenience service offered by the TSA Pre/ ®
service provider and not required by the TSA.

Birth Certificate bearing an official seal (or certified copy) issued by a State,
county, municipal authority (or outlying possession of the U.S.)
Drivers License issued by a State, or outlying possession of the U.S.

*Additional Document

Drivers License issued by a State, or outlying possession of the U.S.
*Does the name you are enrolling under match all documents provided?
Yes

Back

No

Identity

Biographics
Biographics

Disclosure
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Fingerprints Disclosure

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1

EN 05/21/2014@ 8:56 AM

Prove Identity

TSA Pre/ ®

Accepted
*Document Number:

*Driver License Class

123456789

D

*Issuance Date:

*Expiration Date:

11/25/2005

11/24/2015

November 25, 2005

November 24, 2015

*Country of Issue

United States
*State/Province of Issue

Tennessee
HME Endorsement
Comment:

Flatbed Scan

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Biographics

Disclosure
IrisFingerprints
Fingerprints Disclosure

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Fee

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1

EN 05/21/2014@ 8:56 AM

Prove Identity

TSA Pre/ ®

Enter Birth Certificate Information
*Mother’s Maiden Name

Anderson
First Name

Middle Name

Last Name

John

Steven

Smith

Gender

Date of Birth

State/Province of Birth

Male

12/30/1972

Alabama

Suffix

$20 IdentoGO Birth Certificate Certification service fee will be applied. This is an optional convenience service offered by the TSA Pre/ ® service
provider and not required by the TSA.

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Identity

Biographics
Biographics

Disclosure
IrisFingerprints
Fingerprints Disclosure

Fee
Fee

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Payment

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1

EN 05/21/2014@ 8:56 AM

TSA Pre/
Pre/ ®
®
TSA

Prove
Prove Identity
Enter
Enter Birth Certificate Information
*Mother’s Maiden Name

Anderson
Anderson
First
F rst Name
i ohn
John

Middle
M ddle Name
i teven
Steven
S

Gender
Gender

Date
Date of Birth

Male
Male

Last
ast Name

Suffix
Suffix

Smith
Smith

State/Province
tate/Province
of BirtBirth
h
ate/Province
of Birth
Problem with ‘Mother’s St
Maiden
Name’
provided
972
Alabama
labama
12/30/1
2/30/1972
Al
abama

There was a problem certifying the birth certificate using the ‘Mother’s Maiden Name’
provided. Choose one of the following options:

cation service
service fee
fee will be applied.
offeredby
bythe
the TSA Pre/
$20 IdentoGO Birth Certificate Certifi
Certification
applied. This
Pre/ ® service
service
This is
is an
an optional
optionalconvenience
convenience service
service offered
payment
only.
provider and not required by the TSA. Credit
1. If thecard
mother’s
maiden
name is incorrect, click ‘OK’ to correct the information and
try again.
2. Click ‘Cancel Enrollment’ to terminate enrollment. Customer must return at another
time to complete enrollment

OK

Back
Back

Identity
Identity

Biographics
Biographics

Cancel Enrollment

Disclosure
IrisFingerprints
Fingerprints Disclosure

Fee
Fee

Payment
Payment

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1

EN 05/21/2014@ 8:56 AM

TSA Pre/
Pre/ ®
®
TSA

Prove
Prove Identity
Enter
Enter Birth Certificate Information
*Mother’s Maiden Name

Anderson
Anderson
First
F rst Name
i ohn
John

Middle
M ddle Name
i teven
Steven
S

Last
ast Name

Gender
Gender

Date
Date of Birth

State/Province
State/Province of Birth

Suffix
Suffix

Smith
Smith

Male
Male

12/30/1972
Alabama
2/30/1972
Alabama
cation
service
fee will be applied. This is an optional convenience service
System
error
$20 IdentoGO Birth Certificate Certifi
offeredby
bythe
the TSA Pre/
Certification
service
fee will be
applied. This is an optional convenience service offered
Pre/ ® service
service
Credit
card payment
only.
provider and not required by the TSA. Credit
payment
only.
Unablecard
to confirm
birth certificate
due to a system error. Click ‘Cancel Enrollment’ to
terminate enrollment. Customer must return at another time to complete enrollment

Cancel Enrollment

Back
Back

Identity
Identity

Biographics
Biographics

Disclosure
IrisFingerprints
Fingerprints Disclosure

Fee
Fee

Payment
Payment

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1

EN 05/21/2014@ 8:56 AM

TSA Pre/
Pre/ ®
®
TSA

Prove
Prove Identity
Enter
Enter Birth Certificate Information
*Mother’s Maiden Name

Anderson
Anderson
First
F rst Name
i ohn
John

Middle
M ddle Name
i teven
Steven
S

Last
ast Name

Gender
Gender

Date
Date of Birth

State/Province
State/Province of Birth

Suffix
Suffix

Smith
Smith

Male
Male

12/30/1972
Alabama
2/30/1972
Alabama
cation
service
fee
will
be
applied.
This is an optional convenience service
No match found
Credit
card
payment
only.
offeredby
bythe
the TSA Pre/
$20 IdentoGO Birth Certificate Certifi
Certification service fee will be applied. This is an optional convenience service offered
Pre/ ® service
service
No birth certificate match was found using the information provided. Click ‘Cancel
provider and not required by the TSA. Credit
card
payment
only.
Enrollment’ to terminate enrollment. Customer must return at another time to complete
enrollment

Cancel Enrollment

Back
Back

Identity
Identity

Biographics
Biographics

Disclosure
IrisFingerprints
Fingerprints Disclosure

Fee
Fee

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Payment

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1

EN 05/21/2014@ 8:56 AM

Capture Biographics

TSA Pre/ ®

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

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EN 05/21/2014@ 8:56 AM

Capture Biographics

TSA Pre/ ®

Enter Personal Information
First Name

Middle Name

Last Name

John

Steven

Smith

Suffix

Date of Birth

Gender

12/30/1972

Male

December 30, 1972

US

Metric

* Height

6

ft

* Weight

2

in

205

lbs

* Hair Color

* Eye Color

Brown

Multi-color

Social Security Number

Social Security Number

*********

Back

111-08-5114

Identity
Identity

Biographics
Biographics

Disclosure
IrisFingerprints
Fingerprints Disclosure

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Fee

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1

EN 05/21/2014@ 8:56 AM

Capture Biographics

TSA Pre/ ®

Enter Mailing Address
* Country

United States
* Address Line 1

15 Century Blvd
Address Line 2

* City

* State/Province

* Postal Code

Nashville

Tennessee

37214 - 0129

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Identity

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Biographics
Biographics

Disclosure
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Fingerprints Disclosure

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1

EN 05/21/2014@ 8:56 AM

Capture Iris

TSA Pre/ ™
Look Directly At Device

Comment:

Capture

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Identity
Identity

Disclosure
Biographics
Fingerprints Disclosure
Fee
Fee
Biographics
PaymentIrisFingerprints
Biographics
Iris
Fingerprints
Fee

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Disclosure

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1

EN 05/21/2014@ 8:56 AM

Capture Iris

TSA Pre/ ™
Accepted

Comment:

Capture

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Identity
Identity

Disclosure
Biographics
Fingerprints Disclosure
Fee
Fee
Biographics
PaymentIrisFingerprints
Biographics
Iris
Fingerprints
Fee

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1

EN 05/21/2014@ 8:56 AM

Capture Iris

TSA Pre/ ™
Look Directly At Device

Comment:

Capture

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Identity
Identity

Disclosure
Biographics
Fingerprints Disclosure
Fee
Fee
Biographics
PaymentIrisFingerprints
Biographics
Iris
Fingerprints
Fee

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Disclosure

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1

EN 05/21/2014@ 8:56 AM

Capture Iris

TSA Pre/ ™
Accepted

Comment:

Capture

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Identity
Identity

Disclosure
Biographics
Fingerprints Disclosure
Fee
Fee
Biographics
PaymentIrisFingerprints
Biographics
Iris
Fingerprints
Fee

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Disclosure

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1

EN 05/21/2014@ 8:56 AM

Capture Fingerprints

TSA Pre/ ®
Accepted

2

4

3
Right Fingers

5

4

2
5

Back

Identity
Identity

Disclosure
Biographics
FingerprintsDisclosure
Fee
Fee
Biographics
PaymentIrisFingerprints
Fingerprints
Biographics
Iris
Fingerprints
Fee

Payment
Payment
Disclosure

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1

EN 05/21/2014@ 8:56 AM

Capture Disclosure

TSA Pre/ ®

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, 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),
or found not guilty by reason of insanity, of any disqualifying felony listed in TSA Eligibility Requirements, Part B, in any jurisdiction,
military or civilian, during the 7 years before the date of this application?

Yes

No

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

Yes

No

5. Are you wanted or under indictment for any disqualifying crime listed in TSA Eligibility Requirements, Part A and B?

Yes

No

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

Identity
Identity

Disclosure
Biographics
Fingerprints Disclosure
Fee
Fee
Biographics
PaymentIrisFingerprints
Fingerprints
Biographics
Disclosure
Iris
Fingerprints
Fee

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Disclosure

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1

EN 05/21/2014@ 8:56 AM

Capture Disclosure

TSA Pre/ ®

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 Pre/ ® 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 Pre/ ® application program by TSA.
Applicant Signature:

John S. Smith

Comment:

Translator used to interpret disclosure
Comment:

Scan

Identity
Identity

Disclosure
Biographics
Fingerprints Disclosure
Fee
Fee
Biographics
PaymentIrisFingerprints
Fingerprints
Biographics
Disclosure
Iris
Fingerprints
Fee

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1

EN 05/21/2014@ 8:56 AM

Determine Fee

TSA Pre/ ®

Calculate Fee
$85.00 - Full Fee (TSA Pre/ ® expires approximately May 2018)

$85.00

Authorization Code

Apply
IdentoGO Birth Certificate Certification service fee*

$20.00

*IdentoGO Birth Certificate Certification is an optional convenience service offered by the TSA Pre/ ® service provider and not required by the TSA.

Amount Due: $105.00

Credit card only
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Identity
Identity

Disclosure
Biographics
Fingerprints Disclosure
Fee
Fee
Biographics
PaymentIrisFingerprints
Fingerprints
Biographics
Disclosure
Iris
Fingerprints
Fee

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Payment
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1

EN 05/21/2014@ 8:56 AM

Collect Payment

TSA Pre/ ®

Select Payment Method

Amount Due: $105.00

Credit Card
Enter Card
Card Information
Information
Enter
We Accept

* Name on Card

John Smith
* Credit Card Number

4444657591231475
* Expiration Date

* CSC

08

152

/

14

Charge

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Identity
Identity

Disclosure
Biographics
Fingerprints Disclosure
Fee
Fee
Biographics
PaymentIrisFingerprints
Fingerprints
Biographics
Disclosure
Iris
Fingerprints
Fee

Payment
Payment
Disclosure

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1

EN 05/21/2014@ 8:56 AM

Voluntary Customer Survey

TSA Pre/ ®

Answer Survey Questions
1. Are you satisfied with the your overall experience at the enrollment center today?
2. If you experienced an issue that required a resolution, are you satisfied with the resolution?
3. Did the enrollment center representative(s) conduct themselves in a professional and courteous manner?
4. Are you satisfied with the enrollment center appearance?
5. Are you satisfied with the enrollment center location?
If no, please select from one of the following reasons:
1 - Not convenient to work
2 - Not convenient to home
3- Not convenient to highways
4- Not convenient to public transportation
5 - Location is not in a desirable area
6. How did you hear about the TSA PreCheck Application Program?
1 - Sign/brochure at airport
2 - Family/friend
3- Co-worker/Enp
4- Media/News Article
5 - Advertisement
6 - Social Media

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Identity

Disclosure
Biographics
Fingerprints Disclosure
Fee
Fee
Biographics
PaymentIrisFingerprints
Fingerprints
Biographics
Disclosure
Iris
Fingerprints
Fee

Payment
Payment
Disclosure

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1

EN 05/21/2014@ 8:56 AM

Submit Enrollment

TSA Pre/ ®

Access Agent’s TWIC

Place Right or Left Finger on Device

*PIN

******

Access

By placing my finger on the device,
I, STEVEN JONES, certify that the
information captured for John Smith
has been reviewed and verified.

Steven Jones

Identity
Identity

Disclosure
Biographics
Fingerprints Disclosure
Fee
Fee
Biographics
PaymentIrisFingerprints
Fingerprints
Biographics
Disclosure
Iris
Fingerprints
Fee

Payment
Payment
Disclosure

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1

EN 05/21/2014@ 8:56 AM

Submit Enrollment

TSA Pre/ ®

Summary

Customer:

JOHN S. SMITH

KTN:

UNASSIGNED
U11F-193H9F

UE ID:
TSA PRE/ ® ENROLL

85.00

IdentoGO BC CERTIFICATION

20.00

Total Fee:

105.00

Auth Code: 3154N66515RYZB

85.00

CARD (1475):

20.00

Auth Number:

123ABC

Date/Time:
07/16/2013 / 8:56 AM
Enrollment Location:
Nashville, TN (8023)
Notification Method:
[email protected]

Customer Support:
universalenroll.dhs.gov
Reprint

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Identity

Disclosure
Biographics
Fingerprints Disclosure
Fee
Fee
Biographics
PaymentIrisFingerprints
Fingerprints
Biographics
Disclosure
Iris
Fingerprints
Fee

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Finish

Submit
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1

EN 05/21/2014@ 8:56 AM