APPLICANT INFORMATION THIS SECTION MUST BE …

WARNING: This record contains Sensitive Security INFORMATION that is controlled under 49 CFR parts 15 and 1520. No part of this record may be disclosed to persons without a need to know , as defined in 49 CFR parts 15 and 1520, except with the written permission of the Transportation Security Administration or the Secretary of Transportation. Unauthorized release may result in civil penalty or other action. For government, public disclosure is governed by 5 552 and 49 CFR parts 15 and 1520. LAX Security Badge Request Form /201 APPLICANT INFORMATION THIS SECTION MUST BE COMPLETED BY APPLICANTLAST NAME( APPLICANT )FIRST NAMEMIDDLE NAMESUFFIXHOME ADDRESS (No Box)APT. #CITYSTATEZIP CODESOCIAL SECURITY NUMBERCONTACT #DATE OF BIRTH(MM/DD/YYYY)--( ) -/ /E-MAIL ADDRESS ( APPLICANT ):HEIGHTWEIGHTGENDEREYE COLORHAIR COLOR Lbs Female MaleBlackBlueBrownGreenGreyHazelBaldBlac kBlondeBrownGrey RedETHNICITYPLACE OF BIRTH (State/Province)COUNTRY OF BIRTHCITIZENSHIP COUNTRYA sian Black Caucasian Hispanic Native AmericanOtherMust verify identification from TSA approved list of documents which can be found at ID TYPESACCEPTABLE ID #EXP.

I certify that I have read this form in its entirety and understand that if I am convicted or found not guilty by reason of insanity to any of these disqualifying crimes after I receive an LAX Security Badge, I am to report the conviction and surrender all badge(s) within 24 hours to the LAX Security Credentials Section (Badge Office). Grey Black

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