INSTRUCTIONS: Complete
all applicable fields. In Section I, check the Maryland Three
(MD-3) airport where you are based. If you
own an aircraft, complete
all of Section III. If you
do not own an aircraft,
leave make/model and FAA Registration No. fields blank in
Section III. Take this form to the FAA Flight Standard District
Office (FSDO) for an official to sign and to also to your
selected airport for the Airport Security Coordinator to sign.
Submit completed application via fax to (571) 227-2948.
SECTION I. MD-3 Airports Access
Check One: College Park
Hyde Field Potomac Air Field
Transient
SECTION II. Applicant Information
Name:
Date of Birth:
SSN Last 4 digits:
Home Address:
City:
State:
Zip:
SECTION III. Airman/ Aircraft Information
Airman Certificate No.:
ATP
Commercial Private
Student
Aircraft Make/Model (e.g., enter “C-172” if a
Cessna 172):
FAA Registration No.:
SECTION IV. Approvals
Part A. FAA FSDO Official
I have inspected the applicant’s airman certificate,
flight medical certificate, and all other appropriate
information.
Print Name:
Signature:
Date:
Phone No.:
FAA Inspector No. on 110A:
Part B. DCA Security Coordinator
The applicant has been fingerprinted and completed the
appropriate paperwork for a background check. Reference code SON
= 644F / SOI = TD30.
Print Name:
Signature:
Date:
Phone No.:
I have completed
the TSA-approved security training module under the supervision
of the airport security coordinator. I will comply with the
procedures outlined in the security training. I have been
provided an opportunity to ask questions of the airport manager
or been directed by the airport manager to appropriate Federal
Aviation Administration (FAA), Transportation Security
Administration (TSA), or United States Secret Service (USSS)
officials to resolve any questions. I have been apprised of my
security responsibilities, as outlined in the airport security
procedures, and am aware of my reporting and security
responsibilities.
I have completed the items required above and
understand that I may be subject to questioning by FAA, TSA, or
USSS officials as part of airport inspections or surveillance
activities. I further understand that failure to comply with
the airport security procedures may result in suspension of my
privileges to operate an aircraft to or from the airport(s)
indicated above.
Applicant Signature: (Required)
Date:
Part C. Airport Security
Coordinator or Alternate
I have reviewed and photocopied the
applicant’s airman certificate and a government-issued
identification with photograph. I have included a copy of these
documents in the Airport Security Plan. The applicant viewed
the Airport/Pilot Security Briefing tape developed by the FAA,
TSA, and the USSS regarding pilot and airport security
procedures at the airport indicated above.
Print Name:
Signature:
Date:
Phone No.:
PRIVACY
ACT STATEMENT:AUTHORITY:
49 U.S.C. § 114 authorizes collection of this information.
PRINCIPAL
PURPOSE(S):
TSA will use the information to process your application to fly to,
from, or through the airspace of the College Park, Hyde Field, and
Potomac airports located in Maryland. ROUTINE
USE(S):
TSA may share this information with FAA when relevant to the
issuance of security clearance, license or other credential. For
further information please consult DHS/TSA 002 Transportation
Security Threat Assessment System. DISCLOSURE:
Voluntary; Failure to provide the requested information may result
in a denial of your request to take off, land, or fly through the
airspace of the Maryland 3 airports.
PAPERWORK
REDUCTION ACT BURDEN STATEMENT:
This
is a mandatory collection of information if you wish to fly to, from,
or through the airspace of the College Park, Hyde Field, and Potomac
airports located in Maryland. The total average burden per response
associated with this collection is estimated to be approximately
13.75 hours. Send comments regarding this burden estimate or any
other aspect of this collection to: TSA-11, Attention: PRA
1652-0029, 601 South 12th
Street, Arlington, VA 22202. 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 1652-0029, which
expires 8/31/2015.
Previous editions of this form are obsolete.
TSA Form 418 (8/12) rev. [File: 2000.2]
OMB
Control No. 1652-0029; Expiration Date: 8/31/2015.