Form TSA Form 2212 TSA Form 2212 TWIC® Disclosure and Certification

TWIC^® Disclosure and Certification

INSTRUCTIONS: If you must obtain a Transportation Worker Identification Credential (TWIC®), you are required to undergo a security threat assessment. To undergo this assessment, all applicants must provide information requested below and the appropriate documentation to verify their identity and eligibility as part of enrollment. To complete the enrollment process, applicants may pre-enroll at https://universalenroll.dhs.gov, and must visit an enrollment center to provide required documentation, biographic/biometric information and a non-refundable payment within 120 days of pre-enrollment (if applicable). If you are initially deemed ineligible, you will receive a “Preliminary Determination of Ineligibility” letter. You may then be eligible to appeal or apply for a waiver. If you apply for an appeal, you have the opportunity to provide documentation to TSA that corrects incomplete or incorrect information. If you apply for a waiver, you have the opportunity to provide additional information/documentation to TSA in support of your eligibility. [Note: if you are currently under indictment or have open felony charges, it is recommended that you wait to apply for a TWIC® until the matter is resolved.]

SECTION I – DISCLOSURE
Part A. Acknowledgments – Review each statement and respond by checking Yes or No, as appropriate.
I am:  required to have unescorted access to secure areas of maritime facilities or vessels in which a TWIC is required; or applying to be a credentialed merchant mariner; or a commercial driver licensed in Canada or Mexico transporting hazardous materials in accordance with 49 CFR 1572.201; or authorized by TSA to complete the TWIC® security threat assessment and/or apply for a TWIC®.		Yes No
I understand that if I plan on applying for or renewing a Coast Guard (CG)-issued merchant mariner credential, but do not provide my Social Security Number and proof of citizenship during enrollment, I will be required to visit a CG Regional Examination Center to provide this information before my application for the CG-issued credential will be considered complete.		Yes No
I acknowledge that if the Transportation Security Administration (TSA) or another law enforcement agency determines that I pose a security threat, my employer may be notified of this information.  As such, TSA may provide limited information necessary to reduce the risk of injury or damage to any affected area or facility.		Yes No
I am: (check the box that applies)
a U.S. Citizen or U.S. National; or		Yes No
not a U.S. Citizen or U.S. National, but fall into a category listed on page 3 and am eligible for a TWIC®.		Yes No
I understand that when I pick up my renewal/replacement TWIC®, I am responsible for turning in my previous TWIC®.		Yes No
Part B. Criminal History – Review each statement and respond by checking Yes or No, as appropriate. (Please refer to page 4)
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, Disqualifying Criminal Offenses - Part A), in any jurisdiction, military or civilian?		Yes No
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, Disqualifying Criminal Offenses - Part B) in any jurisdiction, military or civilian, in the last 7 years before the date of this application?		Yes No
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, Disqualifying Criminal Offenses - Part B), during the 5 years before the date of this application?		Yes No
Are you wanted or under indictment for any disqualifying crime listed in 49 CFR 1572.103 (see below, Disqualifying Criminal Offenses - 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
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
6. I understand that I must return my TWIC® to the address provided on the credential if I: am currently, or become, wanted, under indictment for, convicted, or found not guilty by reason of insanity, of a felony listed in 49 CFR 1572.103 (see below, Disqualifying Criminal Offenses - Parts A and B) ; am found to be lacking mental capacity or involuntarily committed to a mental health facility; or no longer meet the immigration standards as indicated by a “Yes” response on page 3 of this form.		Yes No
SECTION II – CERTIFICATION
Please review and certify the responses provided in this form by printing and signing your name with a date. If help/translation assistance is provided, contact information for the helper/translator is required should follow up be necessary. For applicants and helpers/translators, a knowing and willful false statement or an omission of a material fact in this form is punishable by fine or imprisonment or both (see 18 U.S.C. 1001), and may be grounds for denial of a TWIC.
Applicants: I understand my continuing obligation to disclose to 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 TWIC® program. The information I have provided on this form 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 18 U.S.C. 1001), and may be grounds for denial of my application for the TWIC® program. Printed Name of TWIC® Applicant	Helpers/Translators: I certify that I provided assistance in the completion of this form at the request of the named applicant; the responses provided are based on information of which I have knowledge or which was provided to me by the applicant; and I have read the completed form to the applicant in the language he/she speaks fluently for verification before he/she signed the application in my presence.
Signature of TWIC® Applicant Date Daytime Telephone Email Address	Printed Name of Helper/Translator Signature of Helper/Translator Date Daytime Telephone

PRIVACY ACT STATEMENT: Authority: 6 U.S.C. § 1140, 46 U.S.C. § 70105; 49 U.S.C. §§ 106, 114, 5103a, 40103(b)(3), 40113, 44903, 44935-44936, 44939, and 46105; the Implementing Recommendations of the 9/11 Commission Act of 2007, § 1520 (121 Stat. 444, Public Law 110-52, August 3, 2007); and Executive Order 9397, as amended.. Principal Purpose(s): The Department of Homeland Security (DHS) will use your information to conduct a security threat assessment. Your fingerprints and associated information will be provided to the Federal Bureau of Investigation (FBI) for the purpose of comparing your fingerprints to other fingerprints in the FBI’s Next Generation Identification (NGI) system or its successor systems including civil, criminal, and latent fingerprint repositories. The FBI may retain your fingerprints and associated information in NGI after the completion of this application and, while retained, your fingerprints may continue to be compared against other fingerprints submitted to or retained by NGI. DHS will also transmit your fingerprints for enrollment into Automated Biometrics Identification System (IDENT). If you provide your Social Security Number (SSN), DHS may provide your name and SSN to the Social Security Administration (SSA) to compare that information against SSA records to ensure the validity of the information. Routine Use(s): In addition to those disclosures generally permitted under 5 U.S.C. 522a(b) of the Privacy Act, all or a portion of the records or information contained in this system may be disclosed outside DHS as a routine use pursuant to 5 U.S.C. 522a(b)(3) including with third parties during the course of a security threat assessment, employment investigation, or adjudication of a waiver or appeal request to the extent necessary to obtain information pertinent to the assessment, investigation, or adjudication of your application or in accordance with the routine uses identified in the TSA system of records notice (SORN) DHS/TSA 002, Transportation Security Threat Assessment System, or DHS/TSA 021, TSA Pre✓® Application Program for applicants to that program. Records may be disclosed to contractors and their agents, grantees, experts, consultants, and others performing or working on a contract, service, grant, cooperative agreement, or other assignment for DHS, when necessary to accomplish an agency function related to this system of records. For as long as your fingerprints and associated information are retained in NGI, your information may be disclosed pursuant to your consent or without your consent as permitted by the Privacy Act of 1974 and all applicable Routine Uses as may be published at any time in the Federal Register, including the Routine Uses for the NGI system and the FBI’s Blanket Routine Uses. Disclosure: Furnishing this information (including your SSN) is voluntary; however, if you do not provide your SSN or any other information requested, DHS may be unable to complete your application for a security threat assessment. PAPERWORK REDUCTION ACT STATEMENT: TSA is collecting this information to determine your eligibility for a TWIC®. This is a voluntary collection of information but failure to provide the information may result in an inability to approve your eligibility for a TWIC®. TSA estimates that the total average burden per response associated with this collection for enrollment is approximately sixty six (66) 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 assigned to this collection is OMB 1652-0047, which expires 07/31/2017.

I am not a U.S. citizen or national, but fall into a category listed below which permits me to hold a TWIC®

Lawful permanent resident (LPR) of the U.S. Refugee admitted under 8 U.S.C. 1157. Alien granted asylum under 8 U.S.C. 1158. Citizen of Micronesia, Marshall Islands, or Palau. Commercial driver who is a citizen of and licensed in Canada or Mexico to transport hazardous materials or admitted to U.S. to conduct business under 8 CFR 214.2(b)(4)(i)(E). Alien in valid F-1 non-immigrant status enrolled at the U.S. Merchant Marine Academy or comparable State maritime academy and sponsored by the U.S. Maritime Administration (MARAD). Alien in valid J-1 non-immigrant status enrolled at the U.S. Merchant Marine Academy or comparable State maritime academy and sponsored by MARAD. Alien in valid M-1 non-immigrant status enrolled at the U.S. Merchant Marine Academy or comparable State maritime academy. Alien in valid R-1 (Religious Workers) status sponsored by MARAD. Alien in a lawful nonimmigrant status with unrestricted authorization to work in the U.S. holding one of the following visas: A-1: Principal alien and immediate family members of an Ambassador, Public Minister, Career Diplomat, Consular Officer, Head of State, with a bilateral agreement in place; A-2: Principal alien and immediate family members of other foreign government officials or employees coming to the United States, including technical and support staff of A-1, with a bilateral agreement in place; A-13 or A-14: Family unity; E-1: Spouse and dependent children of an treaty trader; E-2: Spouse of a treaty investor or employee of a treaty investor spouse; G-1: Principal alien and immediate family member of a principal resident representative of recognized foreign member government to international organization and staff, with a bilateral agreement in place; G-3: Principal alien and immediate family member of a representative of a non-recognized or nonmember foreign government to international organization, with a bilateral agreement in place; G-4: Principal alien and immediate family member of an International organization officer or employee with a bilateral agreement; J-2: Spouse or minor child of exchange visitor; K-3: Spouse of U.S. Citizen (under LIFE Act provisions); K-4: Child of K-3; L-2: Spouse or child of L-1; N-8: Parent of alien classified SK-3 “special immigrant”; N-9: Child of N-8, SK-1, SK-2, or SK-4 “special immigrant”; Principal alien and immediate family members of North Atlantic Treaty Organization (NATO) officials and representatives with bilateral agreement in place: NATO-1, NATO-2, NATO-3, NATO-4, NATO-5, NATO-6; S-7: Spouse, unmarried sons and daughters, and parents of witness or informant;

T-1: Victim of a severe form of trafficking in persons; T-2: Spouse of victim of a severe form of trafficking in persons; T-3: Child of victim of a severe form of trafficking in persons; T-4: Parent of victim of a severe form of trafficking in persons (if T-1 is under 21 years of age); T-5: Unmarried sibling under age of 18 of a T-1 under age of 21; TPS: Temporary protected status (TPS); U-1: Victim of certain criminal activity; U-2: Spouse of U-1; U-3: Child of U-1; U-4: Parent of U-1 (if U-1 is under 21 years of age); U-5: Unmarried sibling under age 18 of a U-1 under age 21; V-1: Spouse of an LPR who is the principal beneficiary of a family-based petition which was filed prior to December 21, 2000, and has been pending for at least 3 years; V-2: Child of an LPR who is the principal beneficiary of a family-based visa petition that was filed prior to December 21, 2000, and has been pending for at least 3 years; OR V-3: The derivative child of a V-1 or V-2. Alien with restricted authorization to work in the U.S. holding one of the following visas: B1-OCS: Business visitor/outer continental shelf (OCS); B-1 or B-1/B-2 with ‘TWIC Letter Received’ annotation: Business visitor requiring a TWIC; BBBCV: B-1/B-2 and Border Crossing Card (Mexicans only); C-1/D: Combined transit and crewman visa; E-1 (Principal): Treaty trader or employee of treaty trader; E-2 (Principal): Treaty investor, or employee of treaty investor; E-3: Australian nationals working in specialty occupations, including spouse; E-3 D: Spouse or child of E-3; E-3R: Returning National of Australia who are professionals coming to the U.S. to perform services in a specialty occupation to uninterrupted employment; H-1B: Specialty occupations; H1-B1: Specialty occupations (professional) (Citizens of Chile or Singapore only) L-1: Intracompany transferees; L-1A: Executive, managerial (intracompany transferee); L-1B: Specialized knowledge professionals; O-1: Extraordinary ability; O-1A: Extraordinary ability in sciences, arts, education, business, or athletics; O-1B: Extraordinary achievement in motion picture and/or television productions; OR TN: Trade visas for Canadian and Mexican business persons seeking to engage in professional activities under the North American Free Trade Agreement (NAFTA). NOTE: The following visa types with unrestricted work authorization are not permitted to obtain a TWIC: K-1: Fiancé or fiancée of U.S. citizen; K-2: Minor child of K-1; S-5: Informant of criminal organization information; OR S-6: Informant of terrorism information.

Disqualifying criminal offenses (49 C.F.R. 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) Racketeer Influenced and Corrupt Organizations Act violations, 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) Racketeer Influenced and Corrupt Organizations Act violations, 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.

Previous editions of this form are obsolete.

Page 3 of 3

TSA Form 2212, March 2017 OMB 1652-0047, which expires 07/31/2017