EFTA01221457.pdf

U.S. VIRGIN ISLANDS PORT AUTHORITY CYRIL E. KING AIRPORT ID BADGE APPLICATION COMPANY (TENANT) NAME SLLC LOCATION.f-s • tileMerril VT :TELEPHONE NO ID APPLICANT/REIQUESTOR NAME: (FIRST NAME) (MID .E !INITIAL) (I AST AME) PHISICAL ADDRESI I MAILING ADDRESS SAME As AbasiE TELEPHONE NO. (II PLACE OF BIRTH: Sl e e,, A'SCMZENSHIP. PASSPORT NO r• • PASSPORT ISSUING CONTRY RESIDENT ALIEN NO. SSNii SEX:MT 0 HAIR COLOR. EYE COLOR Road AOA: YES NO V o DRcI VIN PRII VILEDGE re 0 YES NO TERMINAL El YES 0 NO iA 2 20 0 )( Requesting Supvr /Mgr.. Signature DATE By my signature and wathortud by the above employer (tenant) to execute taiga) this application, I hereby catty that based upon this compsoy's verification of the information entained withia this application, the information presented has bees determined to be true and accurate. As Its representative. I certify that the above employer (Mont) has obtained and will maintain a tea- year employment history and five-year employment verification, on file for the above applicant. I certify that the above company (tenant) will provide Information to the olDelala of the Transportation Security Administration (TSA) or Virgin Islands Port Authority (\TPA) upon request, to include applicable records of those employees who are terminated or whose access is no longer required. The above employer (tenant) agrees that should VIPA be fined by TSA for any security violation resulting from argligeoce by this employer (tenant) associated with this certification: the VIPA will place responsibility on the employer (truant) for reimbursement or direct payment to VIPA for nay floe levied for each violation. SIGNATURE OF EMPLOYER (TENANT) REPRESENTATIVE Name TITLE: DATE: MONTH DATE YEAR THIS CERTIFIES THAT I HAVE RECEIVED FROM THE PORT AUTHORITY A RESTRICTED AREA IDENTIFICATION BADGE/CARD ACCESS MEDIA. I UNDERSTAND THAT THE IDENTIFICATION BADGE/CARD MEDIA REMAINS THE PROPERTY OF TM PORT AUTHORITY: AND MAY BE RECLAIMED BY THE AUTHORITY SHOULD MISUSE OR ABUSE BE DISCLOSED. I FURTHER UNDERSTAND AND AGREE TO ABIDE BY THE RULES AND REGULATIONS SET FORTH BY THE PORT , AUTHORITY AND ANY OTHER RULES AND REGULATIONS CONCERNING THE RESRTICTED AREA IDENTIFICATION BADGE/CARD ACCESS MEDIA FOR MA USE ONLY IDIEEDIA EMPLOYEE APPLICANT SIGNATURE DATE DISAPPROVED APPROVED ID MEDIA ISSUED BY EFTA01221457  ED BADGE APPLICATION PAGE 2 I LEDA( (PAN Ns e.• &SP( &HEREBY AUTHORIZE VIPA SECURITY OFFICE TO CONDUCT A aUMINAL HISTORY RECORD CHECK FOR THE PAST TIN (10) YEARS SIDA NON-SIDA OBLUE/RED a BLUE flREDAVIIITE D ESCORT OMAROONA3REEN OGItEetaED 0 RAMP PRIVILAGE OBLUE & GREEN OBLUERED DARMED OGREEN/RED # BLUE 11WHITE131/JE ISSUE DATE: OBLUEA3REEN EXP.DATE: BADGE J/: I CERTIFY THAT I HAVE READ. UNDERSTAND. AND AGREE TOME FOLLOWING INFORMATION- I. I AGREE TO ABIDE BY THE RULES AND REGULATIONS ESTABLISHED UNDER 49CFR PARTsi 520. 1540. 1542, AND 1544. 2. AN ID BADGE CAN ONLY BE USED BY THE PERSON TO WHOM IT IS ISSUED. 3. EVERY PERSON WHO HAS BEEN ISSUED AN AIRPORT ID BADGE HAS THE INDIVIDUAL. PERSONAL RESPONSIBILITY FOR CHALLENGING ANY INDIVIDUAL IN THE SIDA AREA WHO IS NOT DISPLAYING AN AIRPORT APPROVED ID, OR WHOSE ID DOES NOT MATCH THE BADGE HOLDER 4. LOST OR STOLEN ID BADGES WILL BE IMMEDIATELY REPORTED TO THE VIM SECURITY OFFICE A LOST/STOLEN REPORT MUST BE COMPLETED AT THAT TIME, 5. I AGREE TO RETURN THE ID BADGE TO THE SAFETY AND SECURITY OFFICE SHOULD I QUIT. BE TERM/NATIO TRANSFERRED OR LAID OFF OR LEAVE THE EMPLOYMENT OP THE TENANT; ALSO BEFORE EXPIRATION DATE PRINTED/TYPED ON FRONT OF ID BADGE/MEDIA. 6. ALL. APPLICATIONS MUST LIST ANY CRIMINAL CONVICTIONS OCCURRING IN THE PAST TEN YEARS. 7. ALL APPLICANTS WELL BE SUBJECT TO AN EMPLOYMENT HISTORY VERIFICATION AND A POSSIBLE FBI CRIMINAL HISTORY RECORDS CHECK IF A CRIMINAL HISTORY RECORDS CHECK DISCLOSES A DISQUALIFYING CONVICTION, UNESCORTED ACCESS PRIVILEGES WILL BE DENIED. 8 IF A COPY OF THE CRIMINAL HISTORY RECORD CHECK IS REQUESTED BY THE APPLICANT, THAT REQUEST MUST BE MADE. IN WRITING 9 A WRITTEN RECORD OF ANY INVESTIGATION CONDUCTED WILL BE MAINTAINED BY 1111 EMPLOYER FOR ISO DAYS AFTER TERMINATION OP THE INDIVIDUAL'S UNESCORTED ACCESS PRIVILEGES. O. THE REGULATIONS REQUIRE THAT AN INDIVIDUAL HAS ME RIGHT TOCHALLENGE THE ACCURACY OF HIS HER CRIMINAL HISTORY RECORD. THIS RULE REQUIRES THAT THE INDIVIDUAL MUST NOTIFY THE AIRPORT OPERATOR (VIA) OR ITS DESIGNEE WITHIN 30 DAYS OP RECEIPT OF HIS/HER INTENT TO CORRECT ANY INFORMATION BELIEVED TO BE INACCURATE II. A LIST OF THE. DISQUALIFYING CRIMES FOLLOWS. (SEE. PAGE 3) 12 I UNDF,RSTAND THAT PIE ID MUST BE WORN AND PROPERLY DISPLAYED AT All. TIMES. AND WILL ACCESS ONLY AREAS I AM AUTHORIZED TO BE N. O. THE AIRPORT-ISSUED BADGE/CARD ACCESS MEDIA REMAINS THE PROPERTY OF THE PORT AUTHORITY AT An, TIMES. EFTA01221458  ID BADGE APPLICATION PAGE 3 DISOUALIFYING CRIMINAL OFFENSES HAVE YOU EVER BEEN CONVICTED, OR FOUND NOT GUILTY BY REASON OF INSANTTY, OR ANY OF THE FOLLOWING CRIMES LISTED BELOW IN ANY JURISDICTION IN THE LAST 10 YEARS? 1 Forgery of certificates, faLsc marking of aircraft, and other registration violation, 49 U.S.C. ¢ 46306. YES a NO st.' 2 Interference with air navigation, 49 U.S.C. § 46308. YES o NO fair' 3 Improper transportation of a hazardous material, 49 U.S.C. ¢ 46312. YES o NO c, 4 Aircraft piracy, 49 U.S.C. § 46502. YES a NO are 5 Interference with flight crew members or flight attendants, 49 U.S.C. § 46504. YES o NO so 6 Commission of certain crimes aboard aircraft in flight, 49 U.S.C. § 46506. YES o NO la" 7 Carrying a weapon or explosive aboard aircraft, 49 U.S.C. *46505. YES o NO re 8 Conveying false information and threats, 49 U.S.C. § 46507. YES o NO sr' 9 Aircraft piracy outside the special aircraft jurisdiction of the United States, 49 U.S.C. § 46502. YES o NO re 10 Lighting violations involving transporting controlled substances, 49 U.S.C. § 46502(b). YES o NO tam II Unlawful entry into an aircraft or airport area that serves air carriers or foreign air carriers contrary to established security requitement', 49 U.S.C. I 32. YES o NO se 12 Destruction of an aircraft or aircraft facility, 18 L.S.C. § 32. YES O NO tr) 13 Murder. YES o NO of 14 Assault with intent to murder. YES o NO IV 15 Espionage. YES o NO tai ' 16 Sedition. YES O NO se 17 Kidnapping or hostage taking. YES a NO tai 18 Treason. YES o NO le 19 Rape or aggravated sexual abuse. • YES o NO sr' 20 Unlawful possession, use, sale, distribution, or manufacture or an explosive or weapon YES o NO a' 21 Extortion. YES o NO WI 22 Armed or felony unarmed robbery. YES a NO se 23 Distribution of, or intent to distribute, a controlled substance. YES a NO se' 24 Felony anon. YES o NO se"- 25 A felony involving a threat. YES o NO tr•V 26 A felony involving willful destruction of property. YES o NO eV 27 A felony involving importation or manufacture of a controlled substance. YES O No Ly-' 28 A felony involving burglary. YES o NO cr" 29 A felony involving theft. YES o NO IV 30 A felony involving dishonesty, fraud or misrepresentation. YES a NO V 31 A felony involving possession or distribution of stolen property. YES o NO ra's 32 A felony involving aggravated assault YES a NO eri 33 A felony involving bribery. YES o NO re 34 A felony involving illegal possession of a controlled substance punishable by a YES a NO ci? maximum term of imprisonment of more than one (1) year. 35 Violence at international airports. YES O NO V 36 Conspiracy or attempt to commit any of the crumas1 acts listed above. YES o NO p,' EFTA01221459 ID BADGE APPLICATION PAGE 4 Please initial and sign below Under Federal regulations, 49 CFR 1542.209(1), you have a continuing obligation to disclose to the Port Authority within 24 hours if you are convicted or found not guilty by reason of insanity of any disqualifying criminal offense that occurs while you have unescorted access privileges granted by the Port Authority. I herby certify that I do not have any of the disqualifying criminal offenses listed above. "The information I have provided is true, complete, and correct to the best of my knowledge and belief and provided in good faith. I understand that a knowing and willful false statement can be punished by fine or imprisonment or both (see Section 1001 of Title 18 of the United States Code)." "I authorize the Social Security Administration to release my Social Security Number and full name to the Transportation Security Administration, Office of Transportation Threat Assessment and Credentialing (TTAC), Attention: Aviation Programs (TSA-19)/Aviation Worker Program, 601 South 12"1 Street, Arlington, VA 22202." "I am the individual to whom the information applies and want this information released to verify that my SSN is correct. I know that if I make any representation that I know is false to obtain information from Social Security records, 1 could be punished by fine or imprisonment or both" Signature: SSN and Full Name: EFTA01221460 034,6-2010 II:26am Fro r 1-131 P.001/001 F-603 VRGIN ISLANDS PORT AUTHORITY F.: POLICE DIVISION PO BOX 301707 ST. THOMAS. U.S.V.I. 00803-1707 (340)-714-6655, OR (340)-714-6667 FAX: (340)-714-1494 APPLIC ITION FOR DRIVER'S PERMIT Please Print or Type ST: -Ting s,Lie (Requesting Agency) Lcat I ULM.. 7..:•.7.11 Cm SA-AlIF#- S 14be9 V L Address) (ie g Birth) (Age) Pa) (Height) eight) col( (Driver's Lk No.) (Erpinstion Date) I certify that the individual listed r bone is employed by our corn any and has received instructions to drive safety and in a responsible mannerfor a vehicle • be assigned to him/her, and that he/she must adhere to the Rules and Regulations of th Virgin Islands Port Authority. EFTA01221461