TSA Form 419B CCSF Facility Profile Application

DEPARTMENT OF HOMELAND SECURITY
TRANSPORTATION SECURITY ADMINISTRATION

OMB 1652-0053
Exp. 09/30/2024

CERTIFIED CARGO SCREENING FACILITY (CCSF) PROFILE APPLICATION

INSTRUCTIONS: This form must be completed by companies seeking to be approved 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).
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.
The applicant understands that any fraudulent or false statement made in connection with this application may subject the applicant and the individual completing this
form to both (1) civil penalties under 49 CFR 1540.103(b) and (2) fines and/or imprisonment of not more than five 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:

Indirect Air Carrier Number (if applicable):

SECTION II. Mailing Address (Complete this section only if the mailing address of the facility is different from the physical address)
Company Name:
City:
Telephone Number:

Address:
State:

Zip:

Country or Territory:

Fax Number:

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 09/30/2024
TSA Form 419B (3/16) rev. [File: 400.18]

OMB control number 1652-0053; Expiration Date: 09/30/2024

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SECTION III. Facility Details
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.
☐ Electronics
☐ Pharmaceutical
☐ Freight All Kinds (FAK)

☐ Industrial Materials
☐ Biological
☐ Perishables

☐ Printed Matter
☐ Human Remains
☐ Art

☐ Wearing Apparel
☐ Media

SECTION IV. Contact Information
Facility Security Coordinator - Primary
First Name:

Last Name:

Title:

Primary Telephone Number:

Secondary Telephone Number:

Email Address:

First Name:

Last Name:

Title:

Primary Telephone Number:

Secondary Telephone Number:

Email Address:

Facility Security Coordinator - Secondary

Previous editions of this form are obsolete.
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 079/30/2024
TSA Form 419B (3/16) rev. [File: 400.18]

OMB control number 1652-0053; Expiration Date: 09/30/2024

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