Form TSA 2214 TSA 2214 HTAP Application

HTAP Application

INSTRUCTIONS: Applicants are encouraged to take their time and review all information included on this application for the Hazardous Materials Endorsement Threat Assessment Program (HTAP). Prior to applying, you should confirm with your State licensing entity that you meet the eligibility requirements to hold a Hazardous Materials Endorsement (HME) on your commercial driver’s license. You should also confirm your eligibility based on the TSA requirements by reviewing Section VII “TSA Eligibility Requirements” of this application. You are required to complete the information and provide the documentation requested on this application in order to undergo a security threat assessment. Completed forms (including an applicant’s signature) must be submitted in person at the beginning of the application process. If you are initially disqualified, you may be eligible for an HME and should apply for an appeal or a waiver, which gives you the opportunity to provide additional information and documentation to support your eligibility.  You must wait for a Preliminary Determination of Ineligibility (PDI) letter before applying for an appeal or a waiver.  All fields are required unless otherwise noted. [Note: if you are currently under indictment or have open criminal charges, it is recommended that you wait to apply until the matter is resolved.]

SECTION I -- PERSONAL INFORMATION PERSONAL INFORMATION

NAME (Last, First, Middle, Suffix)      

SOCIAL SECURITY NUMBER (Optional)      

PREVIOUS NAMES USED (Last, First, Middle, Suffix)      

COMMERCIAL DRIVER LICENSE (CDL) NUMBER      

STATE THAT ISSUED CDL      

IF TRANSFERRING HME, LIST PRIOR CDL NUMBER (If known) AND STATE OF ISSUANCE: CDL Number:      State:     

SEX Male Female

DOB (mm/dd/yyyy)       /      /     

HEIGHT       FT.       IN.

WEIGHT       LBS.

HAIR COLOR      

EYE COLOR      

SECTION II -- ADDRESSES

CURRENT RESIDENTIAL ADDRESS      

CITY, STATE, ZIP

CURRENT MAILING ADDRESS (If different than residential address)

CITY, STATE, ZIP

PRIMARY PHONE (Include area code)      

ALTERNATE PHONE (Include area code)      

PREFERRED METHOD OF CONTACT: Phone Email

EMAIL ADDRESS      

PREVIOUS RESIDENTIAL ADDRESS      

CITY, STATE, ZIP      

SECTION III -- CITIZENSHIP

ARE YOU A U.S. CITIZEN OR U.S. NATIONAL?

Yes No

COUNTRY OF CITIZENSHIP      

STATE DEPARTMENT FORM FS-240, FS-545, OR DS-1350 NUMBER (If born abroad to U.S. citizens)      

U.S. PASSPORT NUMBER (If applicable) AND EXPIRATION DATE      

LEGAL STATUS DOCUMENT AND NUMBER (Ref. Page 2, Sec. VI) AND EXPIRATION DATE (If applicable)      

ALIEN REGISTRATION NUMBER (If applicable)      

CITY OF BIRTH      

STATE OF BIRTH (Not required if born outside U.S.)      

COUNTRY OF BIRTH      

SECTION IV -- EMPLOYMENT / ENROLLMENT HISTORY

CURRENT EMPLOYER NAME (If currently in military, put military employment information here)      

CURRENT EMPLOYER PHONE (Include area code)      

CURRENT EMPLOYER ADDRESS      

CITY, STATE, ZIP

1. Have you previously applied and/or been approved for another DHS/TSA background check or credential program (e.g. Global Entry, Transportation Worker Identification Credential, etc.)?

Yes No

2. If yes: Name of program/credential (e.g. Global Entry, Transportation Worker Identification Credential, etc.):       Credential Number (if applicable):      

SECTION V -- CERTIFICATIONS/SIGNATURE

Please refer to “TSA Eligibility Requirements” (Section VII of this form) to answer the following questions.

1. 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 49 CFR 1572.103 (see below, Section VII, Part A), in any jurisdiction, military or civilian?

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 49 CFR 1572.103 (see below, Section VII, Part B), in any jurisdiction, military or civilian, during the 7 years before the date of this application?

Yes No

3. Have you been released from incarceration in any jurisdiction, military or civilian, for committing any disqualifying felony listed in 49 CFR 1572.103 (see below, Section VII, Part B), during the 5 years before the date of this application?

Yes No

4. Are you wanted or under indictment for any disqualifying crime listed in listed in 49 CFR 1572.103 (see below, Section VII, Parts A and B)? Note: If you answered “Yes” to this question because you are currently under indictment or have open criminal charges, you should consider waiting to apply until these matters are resolved as enrollment fees are not refunded.

Yes No

5. 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

I understand my continuing obligation to notify TSA 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 Hazardous Materials Endorsement Threat Assessment 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 Hazardous Materials Endorsement Threat Assessment Program by TSA.

Applicant’s Signature:       Date:      

SECTION VI -- LEGAL STATUS DOCUMENTS

If you possess any of the following documents or cards, please identify it within the “Citizenship” section on page 1 of this form, as well as list the number assigned to your document/card. Please note that a combination of these documents may be required.

Lawful Permanent Residents (LPR) Documents

U.S. Citizenship Documents (Continued)

Unexpired Foreign Passport AND immigrant visa with I-551 annotation of “Upon Endorsement Serves as Temporary I-551 Evidencing Permanent Residence of 1 Year” Unexpired Permanent Resident Card (I-551) Unexpired Re-entry Permit (I-327)

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, municipal authority, or outlying possession of the United States bearing an official seal U.S. Certificate of Citizenship (N-560 or 561) U.S. Citizen Identification Card (I-179 or I-197) U.S. Certificate of Naturalization (N-550 or 570) U.S. military ID card or U.S. retired military ID U.S. military dependent’s card U.S. military discharge papers (DD-214) U.S. civil marriage certificate U.S. social security card Voter’s registration card

U.S. Citizenship Documents

Unexpired Department of Homeland Security (DHS)/Transportation Security Administration (TSA) Transportation Worker Identification Credential (TWIC) Unexpired driver’s license issued by a State or outlying possession of the United States Unexpired Enhanced Tribal Card (ETC) Unexpired Free and Secure Trade (FAST) Card Unexpired ID card issued by a State or outlying possession of the United States. Must include a State or State agency seal or logo Unexpired Merchant Mariner Credential (MMC) Unexpired Merchant Mariner Document (MMD) Unexpired Merchant Mariner License (MML) bearing an official raised seal, or a certified copy Unexpired NEXUS Card Unexpired U.S. Passport (book or card) Unexpired Secure Electronic Network for Travelers Rapid Inspection (SENTRI) Card Unexpired U.S. Enhanced Driver’s License (EDL)

SECTION VII – TSA ELIGIBILITY REQUIREMENTS
Disqualifying Criminal Offenses (49 CFR 1572.103):
Part A: Permanent Disqualifying Criminal Offenses An applicant has a permanent disqualifying offense if convicted, or found not guilty by reason of insanity, in a civilian or military jurisdiction of any of the following felonies: (1) Espionage or conspiracy to commit espionage. (2) Sedition, or conspiracy to commit sedition. (3) Treason, or conspiracy to commit treason. (4) A federal crime of terrorism as defined in 18 U.S.C. 2332b(g), or comparable State law, or conspiracy to commit such crime. Individuals convicted of the crimes in Part A, items (1) - (4) above, are not eligible to apply for a waiver. (5) A crime involving a transportation security incident. 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, as defined in 46 U.S.C. 70101. 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. (6) Improper transportation of a hazardous material under 49 U.S.C. 5124, or a State law that is comparable. (7) Unlawful possession, use, sale, distribution, manufacture, purchase, receipt, transfer, shipping, transporting, import, export, storage of, or dealing in an explosive or explosive device. An explosive or explosive device includes, but is not limited to, an explosive or explosive material as defined in 18 U.S.C. 232(5), 841(c) through 841(f), and 844(j); and a destructive device, as defined in 18 U.S.C. 921(a)(4) and 26 U.S.C. 5845(f). (8) Murder. (9) Making any 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. (10) Violations of the Racketeer Influenced and Corrupt Organizations Act, 18 U.S.C. 1961, et seq., or a comparable State law, where one of the predicate acts found by a jury or admitted by the defendant, consists of one of the crimes listed in paragraph (a) of this section. (11) Attempt to commit the crimes in paragraphs (A)(1) through (A)(4). (12) Conspiracy or attempt to commit the crimes in paragraphs (A)(5) through (A)(10). Individuals convicted of the crimes in Part A, items (5) – (12) above, may be eligible to apply for a waiver. Part B: Interim Disqualifying Criminal Offenses (1) An applicant has an interim disqualifying offense if either: (i) the applicant was convicted, or found not guilty by reason of insanity, of the crime in a civilian or military jurisdiction, within seven years of the date of the application; or (ii) the applicant was incarcerated for that crime and released from incarceration within five years of the date of the TWIC application. (1) Unlawful possession, use, sale, manufacture, purchase, distribution, receipt, transfer, shipping, transporting, delivery, import, export of, or dealing in a firearm or other weapon. A firearm or other weapon includes, but is not limited to, firearms as defined in 18 U.S.C. 921(a)(3) or 26 U.S.C. 5 845(a), or items contained on the U.S. Munitions Import List at 27 CFR 447.21. (2) Extortion. (3) Dishonesty, fraud, or misrepresentation, including identity fraud and money laundering where the money laundering is related to a crime described in paragraphs (A) or (B) of this section. Welfare fraud and passing bad checks do not constitute dishonesty, fraud, or misrepresentation for purposes of this paragraph. (4) Bribery. (5) Smuggling. (6) Immigration violations. (7) Distribution of, possession with intent to distribute, or importation of a controlled substance. (8) Arson. (9) Kidnapping or hostage taking. (10) Rape or aggravated sexual abuse. (11) Assault with intent to kill. (12) Robbery. (13) Fraudulent entry into a seaport as described in 18 U.S.C. 1036, or a comparable State law. (14) Violations of the Racketeer Influenced and Corrupt Organizations Act, 18 U.S.C. 1961, et seq., or a comparable State law, other than the violations listed in paragraph (A)(10) of this section. (15) Conspiracy or attempt to commit the crimes in this paragraph (B). Individuals convicted of the crimes in Part B, items (1) – (15) above, may be eligible to apply for a waiver Part C: Under Want, Warrant or Indictment An applicant who is wanted, or under indictment in any civilian or military jurisdiction for a felony listed in this section, is disqualified until the want or warrant is released or the indictment is dismissed.
Immigration Status (49 CFR 1572.105):
An individual applying for the Hazardous Materials Endorsement Threat Assessment Program must be a citizen or national of the United States or— A lawful permanent resident of the United States; A refugee admitted under 8 U.S.C. 1157; An alien granted asylum under 8 U.S.C. 1158; An alien in valid M–1 nonimmigrant status who is enrolled in the United States Merchant Marine Academy or a comparable State maritime academy. Such individuals may serve as unlicensed mariners on a documented vessel, regardless of their nationality, under 46 U.S.C. 8103; A nonimmigrant alien admitted under the Compact of Free Association between the United States and the Federated States of Micronesia, the United States and the Republic of the Marshall Islands, or the United States and Palau; An alien in lawful nonimmigrant status who has unrestricted authorization to work in the United States, except— An alien in valid S–5 (informant of criminal organization information) lawful nonimmigrant status; An alien in valid S–6 (informant of terrorism information) lawful nonimmigrant status; An alien in valid K–1 (Fianco(e)) lawful nonimmigrant status; or An alien in valid K–2 (Minor child of Fianco(e)) lawful nonimmigrant status. An alien in the following lawful nonimmigrant status who has restricted authorization to work in the United States— B1/OCS Business Visitor/Outer Continental Shelf; C–1/D Crewman Visa; H–1B Special Occupations; H–1B1 Free Trade Agreement; E–1 Treaty Trader; E-2 Treaty Investor; E–3 Australian in Specialty Occupation; L-1A Intracompany Transfer -- Managerial or Executive Positions; L-1B Intracompany Transfer -- Specialized Knowledge Staff; O–1 Extraordinary Ability; or TN North American Free Trade Agreement.

PRIVACY ACT STATEMENT:

Authority: The authority for collecting this information is 49 U.S.C. 114, 114note, and 5103a.

Principal Purpose(s): This information is needed to verify your identity and to conduct a security threat assessment to evaluate your suitability for the Hazardous Materials Endorsement Threat Assessment 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): Routine uses of this information 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; to appropriate governmental agencies for licensing, 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.

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 30 minutes. 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 1652-0027, which expires on 02/28/2013.

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TSA Form 2214, 02/10 [File: 2200.5.1-b] OMB No. 1652-0027 Expires: 02/28/2013