Form TSA Form 3411 TSA Form 3411 Armed Security Officer Voluntary Questionnaire

OMB Control Number: 1652-0035
Expiration: 07/31/2019

DEPARTMENT OF HOMELAND SECURITY

Transportation Security Administration
ARMED SECURITY OFFICER VOLUNTARY QUESTIONNAIRE
INSTRUCTIONS: In order to participate in the Transportation Security Administration (TSA) Law Enforcement/Federal Air Marshal Service's (LE/FAMS)
Armed Security Officer (ASO) Program, this application form must be completed in its entirety. Please fill out all applicable information, sign, date and
return to your assigned field office point of contact (POC). This form shall be stored in accordance with TSA File Code 3400.21.

SECTION I. CANDIDATE INFORMATION
First Name:

Middle Name:

Suffix:

Email Address:

Last Name:

Street Address:
City:

State:

Country:

Zip Code:

Home Phone

Cell Phone:

Birth Date:

US Citizen: ☐ Yes or ☐ No

SECTION II. NOMINATING ENTITY INFORMATION
In order to apply, a candidate must be nominated by a company or organization approved as an aircraft operator and have
security coordinators listed by the DCA Access Standard Security Program (DASSP). Nominating companies may also be a fixed base
operator approved by TSA.
Fixed Based Operator: ☐ YES ☐ NO

Aircraft Operator: ☐ YES ☐ NO

Company Name:
Company Address:
City:
Security Coordinator First Name:

State:

Zip Code:
Security Coordinator Last Name:

Security Coordinator Phone Number:
Security Coordinator Email Address:
Upon qualification, I request to be added to the list of qualified ASOs that may be provided to DASSP approved fixed based operators,
aircraft operators, and security companies that require the list. ☐ YES ☐ NO
☐ I certify this Armed Security Officer Voluntary Questionnaire submission is true and accurate.
☐ I certify I have read the eligibility criteria fully and I meet the requirements for program participation. I also understand the provided
employment information is subject to verification during prior employment background check.
☐ I certify that I have spoken with the security coordinator and they have nominated me to undergo TSA vetting and participation in the
Armed Security Officer Program for general aviation operations into and out of Reagan National Airport.
PRIVACY ACT STATEMENT: AUTHORITY: 49 U.S.C. § 114(f). PRINCIPAL PURPOSE(S): This information will be used to apply to participate in the
ASO Program. ROUTINE USE(S): This information may be shared with another federal agency in response to its request, in connection with the hiring or
retention of an employee or the issuance of a security clearance, or for routine uses identified in TSA system of records, DHS/TSA 002, Transportation
Security Threat Assessment System (T-STAS). DISCLOSURE: Voluntary; failure to furnish the requested information may result in an inability to process
your application to participate in the ASO Program.
PAPERWORK STATEMENT ACT: This is a mandatory collection to participate in the ASO Program. The total average burden per response associated
with this collection is estimated to be approximately 50 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 0MB control number. The control number assigned to this collection is OMB 1652- 0035, which will expire
on July 31, 2019. Send comments regarding this burden estimate or collection to: TSA-11, Attention: PRA 1652-0035, 601 South 12th Street, Arlington,
VA 20598-6011.

TSA Form 3411 (10/18) [File 3400.21]

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SECTION III. CURRENT/MOST RECENT LAW ENFORCEMENT EMPLOYER INFORMATION
ASO applicants MUST list all current and prior law enforcement employment. If you have more than four previous law enforcement
positions to report please supply the additional law enforcement employment information on a separate page.
Current Employer Name:
Current Employer City:

Current Employer State:

Current Employer Country:

Current Employer Zip Code

Current Employer Phone:

Current Employer Fax:

Current Employer Job Title:
Current Employer Job Status: ☐ Full Time or ☐ Part Time

Current Employer Start:

End Date:

SECTION IV. PREVIOUS LAW ENFORCEMENT EMPLOYMENT
PREVIOUS EMPLOYER 1:
Previous Employer Name:
Previous Employer City:

Previous Employer State:

Previous Employer Country:

Previous Employer Phone:

Previous Employer Fax:

Previous Employer Job Title:

Previous Employer Job Status: ☐ Full time or

☐ Part time

Previous Employer Start Date:

Previous Employer End Date:
Previous Employer Reason for Leaving:
(Use space provided):

Previous Employer Supervisor First Name:
Previous Employer Supervisor Last Name:
Previous Employer Supervisor Phone Number:
PREVIOUS EMPLOYER 2:
Previous Employer Name:
Previous Employer City:

Previous Employer State:

Previous Employer Country:

Previous Employer Phone:

Previous Employer Fax:

Previous Employer Job Title:

Previous Employer Job Status: ☐ Full time or ☐ Part time

Previous Employer Start Date:

Previous Employer End Date:
Previous Employer Reason for Leaving
(Use space provided):

TSA Form 3411 (10/18) [File: 3400.21]

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Previous Employer Supervisor First Name:
Previous Employer Supervisor Last Name:
Previous Employer Supervisor Phone Number:
PREVIOUS EMPLOYER 3:
Previous Employer Name:
Previous Employer City:

Previous Employer State:

Previous Employer Country:

Previous Employer Phone:

Previous Employer Fax:

Previous Employer Job Title:

Previous Employer Job Status: ☐ Full time or ☐ Part time

Previous Employer Start Date:

Previous Employer End Date:

Previous Employer Reason for Leaving (Use space below):

Previous Employer Supervisor First Name:
Previous Employer Supervisor Last Name:
Previous Employer Supervisor Phone Number:
SECTION V. Certification and Release of Information

☐ I certify that, to the best of my knowledge and belief, all of the information provided on this questionnaire is true, accurate, complete,
and is made in good faith.
☐ I understand that if accepted into the ASO program I must be available on my own time to attend all initial and subsequent training
to achieve or retain ASO status.
☐ I understand that if credentialed as an ASO I must be willing and may be required to use deadly force in accordance with the
Department of Homeland Security’s Policy Statement 044-05, Department Policy on the Use of Force.
☐ I understand that a false statement on any part of this questionnaire may be grounds for not selecting me for or removing me from the ASO
Program. I also understand that I may be punished by fine or imprisonment for falsification of my voluntary questionnaire in accordance with 18
U.S.C. 1001 and/or other applicable provisions.

Signature:

Date:

PRIVACY ACT STATEMENT: AUTHORITY: 49 U.S.C. § 114(f). PRINCIPAL PURPOSE(S): This information will be used to apply to participate in the
ASO Program. ROUTINE USE(S): This information may be shared with another federal agency in response to its request, in connection with the hiring
or retention of an employee or the issuance of a security clearance, or for routine uses identified in TSA system of records, DHS/TSA 002,
Transportation Security Threat Assessment System (T-STAS). DISCLOSURE: Voluntary; failure to furnish the requested information may result in an
inability to process your application to participate in the ASO Program.
PAPERWORK STATEMENT ACT: This is a mandatory collection to participate in the ASO Program. The total average burden per response associated
with this collection is estimated to be approximately 50 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 0MB control number. The control number assigned to this collection is OMB 1652- 0035, which will
expire on July 31, 2019. Send comments regarding this burden estimate or collection to: TSA-11, Attention: PRA 1652-0035, 601 South 12th Street,
Arlington, VA 20598-6011.

TSA Form 3411 (10/18) [File: 3400.21]

Page 3 of 3