Form TSA Form 419B TSA Form 419B CCSF Facility Profile Application

OMB 1652-0053

Exp. 07/31/2021

DEPARTMENT OF HOMELAND SECURITY

Transportation Security Administration

CERTIFIED CARGO SCREENING FACILITY (CCSF) PROFILE APPLICATION

INSTRUCTIONS: This form must be completed by companies seeking to be designated as a Certified Cargo Screening Facility (CCSF). A separate form must be submitted for each facility. Submit the completed form as part of the CCSF application via email to [email protected] as a protected data file (PDF). Upon receipt of the completed CCSF application package, TSA will distribute the Certified Cargo Screening Program draft regulatory order, the Certified Cargo Screening Program Standard Security Program, the Indirect Air Carrier Standard security Program Alternate Procedures and the Facility Security Plan guidelines as applicable. NOTE: A completed CCSF application consists of TSA Form 419A CCSF Letter of Intent, TSA Form 419B CCSF Facility Profile Application, TSA Form 419C CCSF SSI Acknowledgement, TSA Form 419D Principal Attestation, and TSA Form 419E Security Profile. **Any fraudulent or false statements in conjunction with this application may be subjected to civil penalties under 49 CFR 1540.103(b) and fines and/or imprisonment of not more than 5 years under 18 U.S.C. 1001.**
SECTION I. General Information
Facility Name:		Telephone Number:		Fax Number:
Physical Address:		City:		State:
Zip Code:			Country or Territory:
SECTION II. Mailing Address (Complete this section only if the mailing address of the facility is different from the physical address)
Company Name:			Address:
City:	State:		Zip:		Country or Territory:
Telephone Number:		Fax Number:		Indirect Air Carrier Number (if applicable):
SECTION III. Facility Details
Annual Volume Domestic (lbs):			Annual Volume International (lbs):
Annual Volume Domestic (piece count):			Annual Volume International (piece count):
Annual Volume (lbs) of cargo traveling on passenger aircraft or passenger aircraft (or tendered to a Freight Forwarder):

Annual Volume (piece count-cargo) traveling on passenger aircraft (or tendered to a Freight Forwarder):
Breakdown (%) of volume (cargo) traveling within the US vs. International (if applicable):
Identify the closest airport to your facility (3 letter identifier) (i.e. IAD):
What are the primary commodities shipped by your facility? To better assist your organization during the certification process, please check all applicable boxes and provide a detailed summary of commodities shipped. With this information, our PSIs can tailor their interaction appropriately based on commodity types shipped.
Electronics	Industrial Materials		Printed Matter	Perishables		Wearing Apparel
Pharmaceutical	Biological		Human Remains	Art		Media
Freight All Kinds (FAK)
Summary:
SECTION IV. Contact Information
Facility Contact - Primary
First Name:		Last Name:			Title:
Primary Telephone Number:		Secondary Telephone Number:			Email Address:
Facilty Contact - Secondary
First Name:		Last Name:			Title:
Primary Telephone Number:		Secondary Telephone Number:			Email Address:
Secondary Email Address:

PAPERWORK REDUCTION ACT BURDEN STATEMENT: TSA is collecting this information to qualify entities as Certified Cargo Screening Facilities. The public burden for this collection of information is estimated to be approximately 1.5 hours. This is a mandatory collection of information. Send comments regarding this burden estimate or any other aspect of this collection to: TSA-11, Attention: PRA 1652-0053, 6595 Springfield Center Drive, Springfield, VA 20598. An agency may not conduct or sponsor, and persons are not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number assigned to this collection is 1652-0053, which expires 07/31/2021.

TSA Form 419B (3/16) rev. [File: 400.18]

OMB control number 1652-0053; Expiration Date: 07/31/2021

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