Form TSA Form 419F TSA Form 419F STA Application

DEPARTMENT OF HOMELAND SECURITY

Transportation Security Administration
APPLICATION FOR NEW OR RENEWAL

SECURITY THREAT ASSESSMENT (STA)

All fields are to be completed unless otherwise noted.
SECTION I. General Information
Current STA Number (STA Renewals Only):
Current Employer Name:
City:

Current Employer Corporate Address:
State:

Zip:

Employer Phone Number:

Alabama
IAC Principal (Refer to Section 2 For Definition):
Yes

IAC Principal Title (If IAC Principal):

No

Name (First, Middle, Last Suffix):

Social Security Number (Optional):

Previous Name Used (First, Middle, Last Suffix)(If Applicable):

Previous Name Used (First, Middle, Last)(If Applicable)

Email Address (Optional):

Gender:
Male

Daytime Phone Number:

Place of Birth (City, State, Country):

Date of Birth (MM/DD/YYYY):

Country of Citizenship:

US Passport Number or Certificate of Birth
Abroad Number (If Applicable):

Female

Alien Registration Number (If Applicable):

Naturalization Date (If Applicable):

Naturalization Certificate Number (If Applicable):

Current Mailing Address:

City:

State:

Country:

Alabama
Current Residential Address:

City:

United States of America
Start Date at this Address:

State:

City:

Start Date at this Address:

State:

Previous Residential Address (If Applicable,
See Section 4):

Zip Code:

United States of America
End Date at this Address:

Country:

Zip Code:

United States of America

Alabama

City:

End Date at this Address:

Country:

Alabama
Previous Residential Address (If Applicable,
See Section 4):

Zip Code:

Start Date at this Address:

End Date at this Address:

State:

Country:

Alabama

United States of America

Previous Residential Address (If Applicable,
See Section 4):

Start Date at this Address:

Zip Code:

End Date at this Address:

Previous editions of this form are obsolete.
TSA Form 419F (5/16) rev [File: 400.18]

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City:

State:

Country:

Previous Residential Address (If Applicable,
See Section 4):
City:

Zip Code:

United States of America

Alabama
Start Date at this Address:

End Date at this Address:

State:

Country:

Alabama

United States of America

Zip Code:

SECTION II. Applicant Acknowledgement
This information I have 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, on this application 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 authorization or in the case of parties regulated under this section, removal of authorization to operate under this chapter, if applicable. I acknowledge that if I do not
successfully complete the Security Threat Assessment (STA), the Transportation Security Administration (TSA) may notify my employer. If TSA or other law enforcement agency
becomes aware that I may pose an imminent threat to an operator or facility, TSA may provide limited information necessary to reduce the risk of injury or damage to the operator or
facility.
Applicant Signature:

Date:

I have authenticated the identity and work authorization of the individual for whom this STA application is being submitted by reviewing a Photo Identification issued by a government
authority and work authorization documents as required under 49 C.F.R § 1540.203 (c) (11), and I acknowledge that I am required to retain the individual’s signed STA application, all
documents to prove identity and work authorization, and any communications with TSA regarding the individual’s application (either in electronic or hardcopy format) for 180 days following
at the end of the individual’s service as required under 49 C.F.R. § 1540.203 (d).

SECTION III. Employer Acknowledgement
Employer Signature:

Date:

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SECTION I: Who Needs to Complete a Security Threat Assessmment: The following sections are contained in the Code
of Federal Regulations (CFR).
§ 1548.15 Access to cargo: Security Threat Assessments for individuals having unescorted access to cargo.
a) Before an indirect air carrier authorizes and before an individual performs a function described in paragraph (b)
of this section
1) Each individual must successfully complete a security threat assessment or comparable security threat
assessment described in part 1540 subpart C of this chapter; and
2) Each indirect air carrier must complete the requiremenst in part 1540 subpart C.
b) The security threat assessment required in paragraph (a) of this section applies to the following:
1) Each individual who has unescorted access to cargo and access to information that such cargo will be
transported on a passenger aircraft; or who has unescorted access to cargo screened for transport on a
passenger aircraft; or who performs certain functions related to the transportation, dispatch or security
of cargo for transport on a passenger aircraft or all-cargo aircraft, as specified in the direct air carrier’s
security program; from the time –
i. Cargo to be transported on all cargo aircraft by an aircraft operator with a full all-cargo
program under §1544.101 (h) of this chapter, holds the cargo, until the indirect air
carrier transfers the cargo to an aircraft operator or foreign air carrier; or
ii. Cargo to be transported on a passenger aircraft operated by an aircraft operator with a
full program under § 1544.101 (a) or by a foreign air carrier under §1546.10 (a) or (b) of
this chapter, is accepted by the indirect air carrier, until the indirect air carrier transfers
the cargo to an aircraft operator or foreign air carrier.
2) Each individual the indirect air carrier authorizes to screen cargo or to supervise the screening of cargo
under § 1548.21.
§1548.16 Security Threat Assessment for each proprietor, general partner, officer, director, and certain owners of the
entity.
a) Before an indirect air carrier permits a proprietor, general partner, officer, director, or owner of the entity to
perform those functions
1) The proprietor, general partner, officer, director, or owner, of the entity must successfully complete a
security threat assessment or comparable security threat assessment described in part 1540 subpart C
of this chapter; and
2) Each indirect air carrier must completed the requirements in 49 CFR part 1540, subpart C.
b) For purposes of this section, owner means
1) A person who directly or indirectly owns, controls, or has power to vote 25 percent or more of any class
of voting securities or other voting interests of an IAC or applicant to be an IAC; or
2) A person who directly or indirectly controls in any manner the election of a majority of the directors (or
individuals exercising similar functions) of an IAC, or applicant to be an IAC.
c) For purposes of this definition of owner
1) Members of the same family must be considered to be one person.
i. Same family means parents, spouses, children, siblings, uncles, aunts, grandparents,
grandchildren, first coursins, stepchildren, stepsiblings, and parents-in-law, and spouses
of any of the foregoing.
ii. Each member of the same family, who has an ownership interest in an IAC, or an
applicant to be an IAC, must be identified if the family is an owner as a result of
aggravating the ownership of interests of the same family, any voting interest of any
family member must be taken into account.
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iii.

In determining the ownership of interests of the same family, any voting interest of any
family member must be taken into account.
2) Voting securities or other voting interest means securities or other interests that entitle the holder to
vote for or select directors (or individuals exercising similar functions).
d) Each indirect air carrier, or applicant to be an indirect air carrier, must ensure that each proprietor, general
partner, officer, direrctor, and owner of the entity has successfully completed a Security Threat Assessment
under part 1540, supart C, of this chapter not later than a date to be specified by TSA in a future rule in the
FEDERAL REGISTER.
§ 1549.111 Security Threat Assessment for personnel of certified cargo screening facilities.
a) Scope. This section applies to the following:
1) Each individual the certified cargo screening facility authorizes to perform cargo screening or supervise
cargo screening.
2) Each individual the certified cargo screening facility authorizes to have unescorted access to cargo at any
time from the time it is screened until the time it is tendered to another certified cargo screening
facility, an indirect air carrier under 49 CFR part 1548 for transport on a passenger aircraft, an aircraft
operator under part 1544, or a foreign air carrier under part 1546.
3) The senior manager or representative of its facility in control of the operations.
4) The security coordinators and their alternates.
b) Security Threat Assessment. Before a certified cargo screening facility authorizes an individual to perform the
functions described in paragraph (a) of this section, and before the individual performs those functions
1) Each individual must successfully complete a security threat assessment or comparable security threat
assessment described in part 1540, subpart C of this chapter; and
2) Each certified screening facility must complete the requirements in 49 CFR part 1540, subpart C.
§ 1549.228 Access to cargo and cargo screening: Security Threat Assessment for cargo personnel in the United States.
This section applies in the United States to each aircraft operator operating under a full program under § 1544.101 (a) or
a full all-cargo program under § 1544.101 (h).
a) Before an aircraft operator authorizes and before an individual performs a function described in paragraph (b) of
this section
1) Each individual must successfully complete a security threat assessment or comparable security threat
assessment described in part 1540 subpart C of this chapter; and
2) Each aircraft operator must complete the requirements in part 1540 subpart C.
b) The security threat assessment required in paragraph (a) of this section applies to the following:
1) Each individual who has unescorted access to cargo and access to information that such cargo will be
transported on a passenger aircraft; or who has unescorted access to cargo that ha sbeen screened for
transport on a passenger aircraft; or who performs certain functions related to the transportation,
dispatch, or security of cargo for transport on a passenger aircraft or all-cargo aircraft, as specified in the
aircraft operator’s security program- from the time
i. The cargo reaches a location where an aircraft operator with a full all-cargo program
consolidates or inspects it pursuant to security program requirements until the cargo
enters an airport Security Identification Display Area or is transferred to another TSA
regulated aircraft operator, foreign air carrier, or indirect air carrier; or
ii. An aircraft operator with a full program accepts the cargo until the cargo
 Enters an airport Security Identification Display Area
 Is removed from the destination airport; or
 Is transferred to another TSA regulated aircraft operator, foreign air carrier, or
indirect air carrier.
2) Each individual the aircraft operator authorizes to screen cargo or to supervise the screening of cargo
under § 1544.205.
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§ 1546.213 Access to cargo: Security Threat Assessments for cargo personnel in the United States.
This section applies in the United States to each foreign air carrier operating under § 1546.101 (a), (b), or (e).
a) Before a foreign air carrier authorizes and before an individual performs a function described in paragraph (b) of
this section
1) Each individual must successfully complete a security threat assessment or comparable security threat
assessment described in part 1540 subpart C of this chapter; and
2) Each aircraft operator must complete the requirements in part 1540 supart C.
b) The security threat assessment required in paragraph (a) of this section applies to the following:
1) Each individual who has unescorted access to cargo and access to information that such cargo will be
transported on a passenger aircraft; or who has unescorted access to cargo that has been screened for
transport on a passenger aircraft or all-cargo aircraft, as specified in the foreign air craft operator’s or
foreign air carrier’s security program- from the time
i. The cargo reaches a location where a foreign air carrier under § 1546.101 (e)
consolidates or inspects it pursuant to security program requirements, until the cargo
enters an airport Security Identification Display Area or is transferred to another TSA
regulated aircraft operator, foreign air carrier, or indirect air carrier; or
ii. A foreign air carrier under § § 1546.101 (a) or (b) accepts the cargo, until the cargo
 Enters an airport Security Identification Display Area
 Is removed from the destination airport; or
 Is transferred to another TSA regulated aircraft operator, foreign air carrier, or
indirect air carrier.
2) Each individual the foreign air carrier authorizes to screen cargo or to supervise the screening of cargo
under § 1546.205
SECTION II: IAC Principal Division:
Anyone who is a proprietor, general partner, officer, director, or owner of the entity. Owner means a person who
directly or indirectly owns, controls, or has power to vote 25 percent or more of any class of voting securities or other
voting interests of an IAC or applicant to be an IAC; or a person who directly or indirectly controls inany manner the
election of a majority of the directors (or individuals exercising similar functions) of an IAC, or applicant to be an IAC.
SECTION III: Privacy Act, Paperwork Reduction Act Notices and Paperwork Reduction Act Burden Statement:
Authority: The authority for collecting this information is 49 U.S.C. §§ 114, 5103A, and 40113.
Purpose: This information is needed to verify your identity and to conduct a Security Threat Assessment to evaluate
your suitability for completing the functions required by this position. Failure to furnish your SSN may result in delays in
processing your application, but will not prevent completion of your Security Threat Assessment. Furnishing the other
information is mandatory and failure to provide it may result in you not being granted authorization to have unescorted
access to air cargo subject to TSA security requirements.
Routine Uses: Routine uses of this information include disclosure to TSA contractors orother agents who are providing
services relating to the Security Threat Assessments; to appropriate governmental agencies for 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. For further information, please consult DHS/TSA 002 Transportation
Security Threat Assessment System.
Paperwork Reduction Act Burden Statement: TSA is collecting this information to qualify entitites pursuant to 49 CFR
§§ 1548.15, 1548.16, 1549.111, 1544.228 and 1546.213. The public burden for this collection of information is
estimated to be approximately 15 minutes. This is a mandatory collection of information. Send comments regarding
this burden estimate or any other aspect of this collection to: TSA-11, Attention: PRA 1654.0040 601 South 12th Street,
Arlington, VA 22202. An agency may not conduct or sponsor, and persons are not required to, a collection of
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information unless it displays a currently valid OMB control number. The OMB control number assigned to this
collection is 1652-0040, which expires 03/31/2016.
SECTION IV: Instructions for Completing the Application:
Country of Citizenship: If the applicant is a U.S. citizen born abroad please provide the 10-digit document number from
the applicant’s ertificate of irth !board, Form DS-1350. If the applicant has been naturalized as a US citizen, please
provide your US passport number or your Date of Naturalization and Naturalization Certificate Number. Be sure to
designate that you are a US citizen if you have been naturalized.
Alien Registration Number: Please provide your Alien Registration Number if you are not a US citizen. Please do not
enter an “!” before the !lien Registration Number.
Residential/Physical Address Information: Please provide the last 5 years of residential address information (no PO
Boxes). Use the back of the form or attach an additional sheet if you need to submit more than 5 residential addresses.
Social Security Number: Social Security Number is optional but failure to provide it may result in a delay or prevent
completion of Security Threat Assessment.

Previous editions of this form are obsolete.
TSA Form 419F (5/16) rev [File: 400.18]

OMB control number 1652-0040; Expiration Date: 03/31/2016 Page 6 of 6