Form TSA Form 418 TSA Form 418 MD-3 PIN Application

DEPARTMENT OF HOMELAND SECURITY

Transportation Security Administration
MD-3 PIN APPLICATION
INSTRUCTIONS: Complete all applicable fields. In Section I, check the Maryland Three (MD-3) airport where you are based. If you
own an aircraft, complete all of Section III. If you do not own an aircraft, leave make/model and FAA Registration No. fields blank in
Section III. Take this form to the FAA Flight Standard District Office (FSDO) for an official to sign and to also to your selected airport for
the Airport Security Coordinator to sign. Submit completed application via fax to (571) 227-2948.
SECTION I. MD-3 Airports Access
Check One:

College Park

Hyde Field

Potomac Air Field

SECTION II. Applicant Information
Name:

Date of Birth:

Home Address:

SSN Last 4 digits:

City:

State:

Zip:

SECTION III. Airman/ Aircraft Information
Airman Certificate No.:

ATP

Aircraft Make/Model (e.g., enter “C-172” if a Cessna 172):

Commercial

Private

Student

FAA Registration No.:

SECTION IV. Approvals
Part A. FAA FSDO Official
I have inspected the applicant’s airman certificate, flight medical certificate, and all other appropriate information.
Print Name:

Signature:

Date:

Phone No.:

FAA Inspector No. on 110A:
Part B. DCA Security Coordinator
The applicant has been fingerprinted and completed the appropriate paperwork for a background check. Reference code SON = 644F /
SOI = TD30.
Print Name:

Signature:

Date:

Phone No.:

I have completed the TSA-approved security training module under the supervision of the airport security coordinator. I will comply with
the procedures outlined in the security training. I have been provided an opportunity to ask questions of the airport manager or been
directed by the airport manager to appropriate Federal Aviation Administration (FAA), Transportation Security Administration (TSA), or
United States Secret Service (USSS) officials to resolve any questions. I have been apprised of my security responsibilities, as outlined
in the airport security procedures, and am aware of my reporting and security responsibilities.
I have completed the items required above and understand that I may be subject to questioning by FAA, TSA, or USSS officials as part
of airport inspections or surveillance activities. I further understand that failure to comply with the airport security procedures may result
in suspension of my privileges to operate an aircraft to or from the airport(s) indicated above.
Applicant Signature: (Required)

Date:

Part C. Airport Security Coordinator or Alternate
I have reviewed and photocopied the applicant’s airman certificate and a government-issued identification with photograph. I have
included a copy of these documents in the Airport Security Plan. The applicant viewed the Airport/Pilot Security Briefing tape developed
by the FAA, TSA, and the USSS regarding pilot and airport security procedures at the airport indicated above.
Print Name:

Signature:

Date:

Phone No.:

PRIVACY ACT STATEMENT: AUTHORITY: 49 U.S.C. § 114 authorizes collection of this information. PRINCIPAL PURPOSE(S): TSA will use the information to process your application
to fly to, from, or through the airspace of the College Park, Hyde Field, and Potomac airports located in Maryland. ROUTINE USE(S): TSA may share this information with FAA when relevant
to the issuance of security clearance, license or other credential. For further information please consult DHS/TSA 002 Transportation Security Threat Assessment System. DISCLOSURE:
Voluntary; Failure to provide the requested information may result in a denial of your request to take off, land, or fly through the airspace of the Maryland 3 airports.
PAPERWORK REDUCTION ACT BURDEN STATEMENT: This is a mandatory collection of information if you wish to fly to, from, or through the airspace of the College Park, Hyde Field,
and Potomac airports located in Maryland. The total average burden per response associated with this collection is estimated to be approximately 20 minutes. Send comments regarding this
burden estimate or any other aspect of this collection to: TSA-11, Attention: PRA 1652-0029, 601 South 12th Street, Arlington, VA 22202. 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 1652-0029, which expires
11/30/2018.

Previous editions of this form are obsolete.
TSA Form 418 (8/12) rev. [File: 2000.2]

OMB Control No. 1652-0029; Expiration Date: 11/30/2018.