Form 419H Aviation Security Known Shipper Verification

Aviation Security Known Shipper Verification

INSTRUCTIONS: Print clearly in all fields except for signatures. This form must be completed in its entirety by approved verification firms for the Known Shipper Program and email as a PDF to [email protected] or via fax to (703) 603-0725.

Section 1. Facility and Contact Data
Date of physical visit:      /     /     	Name of business visited:      
Also doing business as (trade name):      					Business type:      
Number of years in business:      			Employer’s Identifying Number:      
Name of individual contacted:      					Title:      
Section 2. Address Information
Physical address:      				City:      			State:      	Zip:      
Mailing address (if different):      				City:      			State:      	Zip:      
Section 3. Shipper’s Contact Information
Physical location phone number:      				Principal contact phone number:      
Emergency phone number:      				Fax number:      
Email address:      @     				Web address:      
Section 4. Verifier’s Information
Name & title of employee or authorized representative verifying the above information:      
Name of aircraft operator, foreign air carrier or indirect air carrier:      		Phone number:      				Email address:      
I certify the above information is true and correct and the onsite visit and verification was conducted in person as required by the TSA standard security program and applicable security directives. This certification is (i) made with the understanding that any intentional falsification may be subject to both civil and criminal penalties under 49 CFR 1540.103 and 18 U.S.C. 1001 and (ii) subject to record keeping requirements approved by TSA.
Signature of Verifier:
Signature of Shipper:

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