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pdfUniversal
EnrollmentNashville
Services TN (8023)
Service Location:
Search
Appointments
*Date of Birth
Last Name
First Name
MI
Program
Service
Appointment
Smith
John
S
HME
Enroll
9:00am
Clever
Joe
D
HME
Enroll
9:15am
Search Method
Grey
Steven
R
TWIC
Activate Card
9:30am
Phone
Thompson
Joanne
C
TWIC
Enroll
10:15am
Country Code
Clark
James
F
Pre
Enroll
10:30am
Gregory
George
S
Pre
Enroll
10:30am
Williams
Amy
A
TWIC
Enroll
10:45am
Hartwell
Paul
R
TWIC
Reset Card PIN
11:00am
Wells
Steve
H
TWIC
Enroll
11:30am
Anderson
Robert
J
HME
Enroll
12:00pm
Cook
John
D
Pre
Enroll
12:15pm
Fellows
Keith
W
TWIC
Reset Card PIN
12:30pm
Simmons
Chris
N
Pre
Enroll
12:45pm
Subject
Hoover
Richard
K
TWIC
Enroll
1:00pm
Service Outage
Lester
David
D
TWIC
Activate Card
1:30pm
Training Module Due
Freeman
Steven
S
TWIC
Enroll
1:45pm
United States (+1)
Phone
Search
Clear
Message Center
Date
! 07/16/13
07/10/13
Print Appointments
Next
Admin
1
EN 7/16/2013 @ 8:56 AM
Universal
EnrollmentNashville
Services TN (8023)
Service Location:
Search
Appointments
*Date of Birth
12/30/1972
December 30, 1972
Search Method
Last Name
First Name
MI
Program
Service
Appointment
Smith
John
S
HME
Enroll
9:00am
Smith
John
S
Walk-in
New
Walk-in
Phone
Country Code
United States (+1)
Phone
615-123-4567
Search
Clear
Message Center
Date
! 07/16/13
07/10/13
Subject
Service Outage
Training Module Due
Next
Admin
1
EN 7/16/2013 @ 7:56 AM
Universal
EnrollmentNashville
Services TN (8023)
Service Location:
Enter Customer Information
Essential
Contact
*First Name
*Preferred Language
John
English
*Middle Name
*Method of Contact 1
Country Code
Steven
United States (+1)
*Last Name
Smith
*Gender
*Primary Method of Contact
Method of Contact 1
Phone
615-123-4567
Suffix
*Method of Contact 2
Method
None
Male
*Date of Birth
12/30/1972
Email Receipt to
[email protected]
December 30, 1972
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Back
1
EN 7/16/2013 @ 8:56 AM
Universal
Services
UniversalEnrollment
Enrollment
Services
Select Program
Select Customer Service
Enroll
Transfer
HazMat
Next
Back
1
EN 7/16/2013 @ 8:56 AM
Universal
Enrollment Services
Prepare Service
Determine Enrollment History
* Commercial Driver License Number
00123456
South Dakota
* Prior CDL information
* Commercial Driver License Number
65465412
Back
*State of Issuance
*State/Province of Issuance
Tennessee
Service
Identity
Fee
Payment
Biographics
Fingerprints
Disclosure
Survey
Next
Submit
1
EN 7/16/2013 @ 8:56 AM
Universal
Enrollment Services
Prove Identity
Determine Citizenship
*Country of Birth
United States
*City of Birth
*State/Province of Birth
Nashville
Tennessee
*Country of Citizenship
United States
Back
Service
Identity
Fee
Payment
Biographics
Fingerprints
Disclosure
Survey
Next
Submit
1
EN 7/16/2013 @ 8:56 AM
Prove Identity
Determine Documents
Documents
Additional Documents
Transportation Worker Identification Credential (TWIC)
Driver’s license issued by a State or outlying possession of the U.S.
Enhanced Tribal Card (ETC)
Free And Secure Trade (FAST) Card
ID card issued by a State or outlying possession of the U.S.
U.S. Passport Book or Passport Card
Merchant Mariner Credential (MMC)
Merchant Mariner Document (MMD)
Merchant Mariner License (MML) with official seal or certified copy
NEXUS Card
U.S. Passport (book or card)
Secure Electronic Network for Travelers Rapid Inspection (SENTRI)
United States Enhanced Driver’s License (EDL)
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,
Back
Service
Identity
Fee
Payment
-AND-
Required Identity Documents:
U.S. Passport Book or Passport Card
Biographics
Fingerprints
Disclosure
Survey
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Submit
1
EN 7/16/2013 @ 8:56 AM
Universal
Enrollment Services
Prove Identity
Accepted
*Document Number:
100003106
*Issuance Date:
*Expiration Date:
11/25/2005
11/24/2015
November 25, 2005
November 24, 2015
Comment:
Scan
Back
Service
Identity
Fee
Payment
Biographics
Fingerprints
Disclosure
Survey
Next
Submit
1
EN 7/16/2013 @ 8:56 AM
Universal
Enrollment
Services
Determine
Fee
Calculate Fee
$86.50 - Full Fee (HME expires approximately May 2014)
$86.50
Authorization Code
Apply
Fee: $86.50
Back
Service
Identity
Fee
Payment
Biographics
Fingerprints
Disclosure
Survey
Next
Submit
1
EN 7/16/2013 @ 8:56 AM
Universal
Enrollment
Services
Collect Payment
y
Choose Payment Method
Credit Card
Check
Amount Due $86.50
Money Order
Swipe Card
We Accept
* Name on Card
John Smith
* Credit Card Number
4444657591231475
* Expiration Date
08
/
14
* CSC
152
Charge
ge
Back
Service
Identity
Fee
Payment
Biographics
Fingerprints
Disclosure
Survey
Next
Submit
1
EN 7/16/2013 @ 8:56 AM
Universal
Enrollment
Services
y
Collect Payment
Choose Payment Method
Credit Card
Check
Amount Due $86.50
Money Order
Swipe Card
We Accept
Credit Card ending in 5012
was successfully charged
$86.50
* Name on Card
John Smith
* Credit Card Number
4444657591231475
* Expiration Date
08
/
14
* CSC
152
Charge
Back
Service
Identity
Fee
Payment
Biographics
Fingerprints
Disclosure
Survey
Next
Submit
1
EN 7/16/2013 @ 8:56 AM
Universal
Services
Capture Enrollment
Biographics
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
Key Pad Functions
1 = Yes
Back
2 = No
7 = Move back to previous question
Service
Identity
Fee
Payment
Biographics
Fingerprints
Disclosure
Survey
Next
Submit
1
EN 7/16/2013 @ 8:56 AM
Universal
Services
Capture Enrollment
Biographics
Enter Personal Information
First Name
Middle Name
Last Name
John
Steven
Smith
Suffix
Date of Birth
Gender
12/30/1972
Male
December 30, 1972
* Maiden/Previous Name
* First Name
* Middle Name
* Last Name
Jimmy
NMN
John
* Alias
* First Name
* Middle Name
* Last Name
Jimmy
Hunter
John
US
Metric
Height
*
6
ft
2
* Weight
in
205
lbs
* Hair Color
* Eye Color
Brown
Multi-color
Social Security Number
Suffix
Social Security Number
*********
Back
Suffix
111-08-5114
Service
Identity
Fee
Payment
Biographics
Fingerprints
Disclosure
Survey
Next
Submit
1
EN 7/16/2013 @ 8:56 AM
Universal
Services
Capture Enrollment
Biographics
Enter Mailing Address
* Country
United States
* Address Line 1
15 Century Blvd
Address Line 2
Suite 110
* City
* State/Province
* Postal Code
Nashville
Tennessee
37214 - 0129
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Service
Identity
Fee
Payment
Biographics
Fingerprints
Disclosure
Survey
Submit
Next
EN 9/25/2012 @ 7:56 AM
Universal
Services
Capture Enrollment
Biographics
Enter Residential Address
* Country
United States
* Address Line 1
123 Elm Hill Pike
Address Line 2
* City
* State/Province
* Postal Code
Nashville
Tennessee
37214 - 0129
Back
Service
Identity
Fee
Payment
Biographics
Fingerprints
Disclosure
Survey
Next
Submit
1
EN 7/16/2013 @ 8:56 AM
Universal
Services
Capture Enrollment
Biographics
Enter Previous Address
* Country
United States
* Address Line 1
125 Main Street
Address Line 2
Suite 110
* City
* State/Province
* Postal Code
Murfreesboro
Tennessee
37129 - 0129
Back
Service
Identity
Fee
Payment
Biographics
Fingerprints
Disclosure
Survey
Submit
Next
EN 9/25/2012 @ 7:56 AM
Universal
Services
Capture Enrollment
Biographics
Enter Employment Information
* Employment Status
Occupation or Trade
Currently Employed
Trucker
* Current Employer Name
* Country
ACME Supply Company
Canada
Address Line 1
123 Great White North Road
Address Line 2
* City
* State/Province
Postal Code
Montreal
Quebec
37214 - 0129
Country Code
Phone
Canada (+1)
408-688-7942
Back
Service
Identity
Fee
Payment
Biographics
Fingerprints
Disclosure
Survey
Next
Submit
1
EN 7/16/2013 @ 8:56 AM
Universal
Services
Capture Enrollment
Fingerprints
Place Fingers on Device
3
2
4
5
Service
Identity
Fee
Payment
Biographics
Fingerprints
Disclosure
Survey
Next
Submit
1
EN 7/16/2013 @ 8:56 AM
Universal
Services
Capture Enrollment
Fingerprints
Passed
3
2
4
3
4
5
2
5
Right Fingers
Rescan
Service
Identity
Fee
Payment
Biographics
Fingerprints
Disclosure
Survey
Next
Submit
1
EN 7/16/2013 @ 8:56 AM
Universal
Services
Capture Enrollment
Fingerprints
Place Thumbs on Device
6
1
Service
Identity
Fee
Payment
Biographics
Fingerprints
Disclosure
Survey
Next
Submit
1
EN 7/16/2013 @ 8:56 AM
Universal
Services
Capture Enrollment
Fingerprints
Passed
6
1
6
1
Rescan
Service
Identity
Fee
Payment
Biographics
Fingerprints
Disclosure
Survey
Next
Submit
1
EN 7/16/2013 @ 8:56 AM
Universal
Services
Capture Enrollment
Fingerprints
Place Fingers on Device
9
8
7
0
Service
Identity
Fee
Payment
Biographics
Fingerprints
Disclosure
Survey
Next
Submit
1
EN 7/16/2013 @ 8:56 AM
Universal
Services
Capture Enrollment
Fingerprints
Passed
9
8
7
8
9
0
7
Right Fingers
Rescan
Service
Identity
Fee
Payment
Biographics
Fingerprints
Disclosure
Survey
Next
Submit
1
EN 7/16/2013 @ 8:56 AM
Universal
Capture Enrollment
DisclosureServices
Answer Questions
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 as enrollment fees are not refunded.
1. Are you a U.S. citizen?
Yes
No
2. Excluding juvenile cases unless convicted as an adult, have you been convicted, pled guilty including “no contest”, or found
not guilty by reason of insanity, of any disqualifying felony listed in 49 CFR 1572.103 (Section VII, 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”, or found
not guilty by reason of insanity, of any disqualifying felony listed in 49 CFR 1572.103 (Section VII, 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 49 CFR 1572.103 (Section VII, 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 listed in 49 CFR 1572.103 (Section VII,
Parts 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
Key Pad Functions
1 = Yes
2 = No
7 = Move back to previous question
Service
Identity
Fee
Payment
Biographics
Fingerprints
Disclosure
Survey
Next
Submit
1
EN 7/16/2013 @ 8:56 AM
Universal
Capture Enrollment
DisclosureServices
Accepted
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.
John S. Smith
Comment:
Translator used to interpret disclosure
Comment:
Scan
Back
Service
Identity
Fee
Payment
Biographics
Fingerprints
Disclosure
Survey
Next
Submit
1
EN 7/16/2013 @ 8:56 AM
Universal
Enrollment
Customer
Survey Services
Answer Survey Questions
Each question is viewable only by you and will allow only one (1) answer.
1. Are you satisfied with the your overall experience at the enrollment center today?
Yes
No
2. If you experienced an issue that required a resolution, are you satisfied with the resolution?
Yes
No
3. Did the enrollment center representative(s) conduct themselves in a professional and courteous manner?
Yes
No
4. Are you satisfied with the enrollment center location and appearance?
Yes
No
NA
Thank you for participating. If you would like to provide additional feedback, please contact UES CUSTOMER SUPPORT at 855-DHS-UES1 (855-347-8371) or
use the ‘Contact Us’ link on the UES website at universalenroll.dhs.gov.
Key Pad Functions
1 = Yes
2 = No
3 = Not Applicable (NA)
Identity
Fee
Payment
7 = Move back to previous question
Biographics
Fingerprints
Disclosure
Survey
9 = Exit Survey
Next
Submit
1
EN 7/16/2013 @ 8:56 AM
Universal
Enrollment Services
Submit Enrollment
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
Back
Service
Identity
Fee
Payment
Biographics
Fingerprints
Disclosure
Survey
Submit
1
EN 7/16/2013 @ 8:56 AM
Universal
Enrollment Services
Submit Enrollment
Summary
Applicant:
JOHN S. SMITH
Known
UE
ID: Traveler Number:
U11F-193H9F
TBD
Service:
HME ENROLL
Fee:
$86.50
Paid:
$86.50
Method:
Website:
universalenroll.dhs.gov
CARD (1475)
Auth Number:
Date/Time:
Enrollment Location:
Notification Method:
Email Receipt to:
Customer Support:
855-DHS-UES1
(855-347-8371)
123ABC
07/16/2013 / 8:56 AM
UES Enrollment Center
1-615-123-4567
[email protected]
Service
Identity
Fee
Payment
Reprint
Biographics
Fingerprints
Disclosure
Survey
Finish
Submit
1
EN 7/16/2013 @ 8:56 AM
Universal
Enrollment Services
Submit Enrollment
Privacy Act and Paperwork Reduction Act Statements
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.
Service
Identity
Fee
Payment
Biographics
Fingerprints
Disclosure
Survey
Submit
1
EN 7/16/2013 @ 8:56 AM
| File Type | application/pdf |
| File Title | HME_workstation_comp.pdf |
| Author | klesuer |
| File Modified | 2013-08-21 |
| File Created | 2013-08-21 |