TSA Form 3412 Armed Security Officer Authorization for Release of Info

OMB Control Number: 1652-0035
Expiration: 11/30/2022

DEPARTMENT OF HOMELAND SECURITY

Transportation Security Administration

Clear Form

ARMED SECURITY OFFICER AUTHORIZATION FOR RELEASE OF INFORMATION
INSTRUCTIONS: In order to participate in the Transportation Security Administration (TSA) Law Enforcement/Federal Air Marshal
Service (LE/FAMS) Armed Security Officer (ASO) Program the participant shall complete all applicable sections below and certify in
Section III. *Note: In Section I, N/A may be listed if no other names besides the applicant's name is used.
This form shall be stored in accordance with TSA File Code TSA File Code 3400.21.
SECTION I. Applicant Information
Applicant's Name (First, Middle, Last)
Other Names Used
Current Address (Street, City, State and Zip)
Home Telephone Number (Include Area Code)
Social Security Number
SECTION II. Release Information
I Authorize any investigator, special agent, or other duly accredited representative of the Transportation Security Administration conducting
the verification of the information provided in my application for participation in the ASO program, including law enforcement employment
verification (to include disciplinary history) and criminal history record checks to disclose the results of these checks to the
Transportation Security Administration for the purpose of making a determination of eligibility for the Armed Security Officer Program.

I also Authorize my prior law enforcement employer(s) to release any and all information relating to my employment with them to the
Transportation Security Administration.

I Understand that the information released by records custodians and sources of information is for official use by the Transportation Security
Administration for the purposes of the Armed Security Officer Program, and that it may be disclosed by the Transportation Security
Administration only as authorized by law.

Copies of this authorization that show my signature are as valid as the original release signed by me. This authorization is valid for five (5)
years from the date signed or upon the termination of my affiliation with the Transportation Security Administration, whichever is sooner.
SECTION III. Certify and Approve
Full Name (Type or Print Legibly)
Applicant's Signature
Date of Signature
PRIVACY ACT STATEMENT: AUTHORITY: 49 U.S.C. § 114; Pub. L.108-176. PRINCIPAL PURPOSES(S): To identify individuals eligible
to serve as armed security officers aboard general aviation flights into DCA. ROUTINE USE(S): This information you provide may be shared
with aircraft and airport operators, and the FAA, or for routine uses identified in TSA system of records, DHS/TSA 002, Transportation
Security Threat Assessment System. DISCLOSURE: Voluntary; failure to furnish the requested information may result in delays in
processing or denial of your nomination.
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 5 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 November 30, 2022. Send comments regarding this burden
estimate or collection to: TSA-11, Attention: PRA 1652-0035, 6595 Springfield Center Drive, Springfield, VA 20598-6011.

TSA Form 3412 (10/18) [File: 3400.21]

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