TSA Form 419D CCSF Principal Attestation

OMB 1652-0053

Exp. 07/31/2021

C CSF Principal Attestation

INSTRUCTIONS: This form is to be completed by any principal, proprietor, general partner, officer, director, or owner of a company seeking to be part of the Certified Screening Program. Please complete the applicable section and sign and date the form. This form must be submitted along with other parts of the CCSF application as a complete package via email as a PDF to [email protected] or via fax (703) 603-0725.

The complete CCSF application package includes TSA Form 419A, CCSF Letter of Intent, TSA Form 419B, CCSF Facility Profile Application, TSA Form 419C, CCSF SSI Agreement, TSA Form 419D Principal Attestation, TSA Form 419C Security Profile.

Section 1. Certification of Previously Approved Vendor
	I       certify that I have been a proprietor, general partner, officer, director, or owner (as defined in 49 CFR 1548.16) of an Indirect Air Carrier (IAC) or Certified Cargo Screening Facility (CCSF) listed below:
     				     
IAC/CCSF Name				IAC/CCSF Number
     		     	     /     /     		     /     /     
Physical City		State	Start Date		End Date
     				     
IAC/CCSF Name				IAC/CCSF Number
     		     	     /     /     		     /     /     
Physical City		State	Start Date		End Date
Section 2. Previously Certified, but Revoked
	I       certify that as a proprietor, general partner, officer, director, or owner, I have had my certification revoked
     		     				     
IAC Number		Physical City, State				Date Revoked
My certification was revoked for the following reason      
Section 3. Not Previously Certified
	I      certify that I have NOT previously been a proprietor, general partner, officer, director, or owner (as defined in 49 CFR 1548.16) of an IAC or CCSF.
Section 4. Signature
Applicant Signature and Date

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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 30 minutes.  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 419D, (04/11) [File: #2000.2] OMB control number 1652-0053; Expiration Date: 07/31/2021