Form CBP Form 3078 CBP Form 3078 Application for Identification Card

DEPARTMENT OF HOMELAND SECURITY
U.S. Customs and Border Protection

OMB APPROVAL NO. 1651-0008
EXPIRATION DATE 11/30/2019
ESTIMATED BURDEN 17 MIN

APPLICATION FOR IDENTIFICATION CARD
19 U.S.C. 66, 1551, 1555, 1565, 1624, 1641;
19 CFR 112.42, 118, 122.182, 146.6
1. TYPE OF ACTIVITY REQUIRING IDENTIFICATION CARD
Cartman/
Lighterman

Broker's
Employee

CBP
Security Area
Identification

Warehouse Officer
or Employee

Container Station
Employee

Foreign
Trade Zone
Employee

2. DATE OF THIS APPLICATION
CES
Employee

3. NAME (Last, First, & Middle)

4. SOCIAL SECURITY NUMBER

5. LIST ANY OTHER NAMES YOU HAVE EVER BEEN KNOWN BY (Nicknames, aliases, etc.)

6. DATE OF BIRTH

7. HOME ADDRESS (Number, Street, City, State, and ZIP Code)

8. NAME AND ADDRESS OF PRESENT EMPLOYER

9. HOME PHONE NUMBER

10. BUSINESS PHONE NUMBER

11. PLACE OF BIRTH (City, County, State, and Country)

12. HEIGHT

13. WEIGHT

14. COLOR HAIR 15. COLOR EYES

16. VISIBLE SCARS OR MARKS
17. U.S. COAST GUARD PORT SECURITY CARD NUMBER

18. U.S. MERCHANT MARINE CARD NUMBER

19. HAVE YOU EVER APPLIED FOR CARD IN ITEM 17 OR ITEM
20. HAS APPLICATION FOR EITHER CARD IN ITEM 17 OR 18 BEEN
18?
DENIED?
YES

(Skip Items 20 and 21)

NO

YES

(If Yes, explain in Item 21)

NO

(Skip Item 21)

21. EXPLANATION OF APPLICATION DENIAL
22. LIST ALL RESIDENCES DURING THE LAST 5 YEARS (List in reverse order, beginning with the present address)
DATES
From

Number and Street

To

City

State

PRESENT

23. HAVE YOU EVER SERVED IN THE ARMED SERVICES OF THE U.S.?
YES

NO

24. BRANCH OF SERVICE

(Skip Items 24-28)

25. DATES OF SERVICE

27. TYPE OF DISCHARGE

26. SERIAL NUMBER

28. IF DISCHARGE WAS OTHER THAN HONORABLE, EXPLAIN IN FULL DETAIL

29. HAVE YOU EVER APPLIED FOR AN IDENTIFICATION CARD WITH
U.S. CUSTOMS AND BORDER PROTECTION?

CBP Form 3078 (3/19)

YES

(If Yes, explain details)

NO

Page 1 of 2

30. PREVIOUS EMPLOYMENT -- LIST IN CHRONOLOGICAL ORDER, GIVING EARLIEST EMPLOYMENT FIRST (Last 10 Years)
DATES
From

To

EMPLOYER NAME AND ADDRESS

OCCUPATION

31. HAVE YOU EVER BEEN CONVICTED OF ANY CRIME OR OFFENSE (Other than traffic violations, you
may exclude any items which occurred before your 16th birthday) IN THIS COUNTRY OR ELSEWHERE?

YES (If YES, explain
in Item 32.)

NO

32. EXPLANATION OF ALL CONVICTIONS (Federal, State, Military, or Foreign)

Date

Place

Charge

33. DO YOU NOW USE OR HAVE YOU EVER USED NARCOTIC DRUGS?

35.
CERTIFICATION

I certify that all of the statements made in this Application are
true, complete, and correct to the best of my knowledge and
belief, and are made in good faith.

Final Disposition

Court

YES (If YES, explain
below.)

NO 34. ATTACH PHOTOGRAPH HERE

SIGNATURE (Sign in ink)

X

DATE

Paperwork Reduction Act Notice: The Paperwork Reduction Act says we must tell you why we are collecting this information, how we will use it, and whether you have
to give it to us. We ask for this information to carry out U.S. Customs and Border Protection laws of the United States. This form is used by licensed cartmen or
lightermen or their employees as an application to apply for a CBP identification card and is required to obtain or retain a benefit. The estimated average burden
associated with this collection of information is 17 minutes per respondent or recordkeeper depending on individual circumstances. The valid OMB Control Number for
this Information Collection is 1651-0008.
Pursuant to 5 U.S.C. § 552a(e)(3), this Privacy Act Statement serves to inform you of why DHS is requesting the information on this form. CBP is authorized to collect
the information requested on this form pursuant to 5 U.S.C. 301, Reorganization Plan No. 1 of 1950; 19 U.S.C. 1551, 1565, 1624, 1641; and 19 CFR 112.42. CBP is
requesting this information to enable CBP to conduct a background investigation and thereby determine whether the applicant meets the criteria required for the
issuance of an identification card. CBP may provide information collected and contained in the applicant’s file to those employees of CBP who have a need for the
records in the performance of their duties. CBP may also use this information, when deemed appropriate, in a proceeding to revoke or suspend the identification card.
The information requested on this form may be shared externally as a “routine use” to other government agencies to assist the Department of Homeland Security in
investigating and assessing an applicant’s eligibility for an identification card. A complete list of the routine uses can be found in the system of records notice associated
with this form, “Department of Homeland Security/ALL-026 DHS Personal Identity Verification Management System.” The Department’s full list of system of records
notices can be found on the Department's website at http://www.dhs.gov/system-records-notices-sorns. Providing this information to CBP is voluntary. However, failure
to provide this information may result in CBP’s inability to conduct the background investigation required to issue the identification card.

CBP Form 3078 (3/19)

Page 2 of 2