City of Chicago Department of Aviation ACCESS CONTROL …

1 City of Chicago Department of Aviation ACCESS CONTROL AND PHOTO ID BADGE. APPLICATION. Step 1 - Application Information To be completed by the APPLICANT. Badge #. Airport: O'Hare (ORD); CAT X Midway Airport (MDW); CAT 1. 1 Application Date: Previous City of Chicago employment? YES NO. 2 Company Name: Company Code: 3 Application Type RENEWAL NEW ID CHANGE LOST STOLEN DF #: DAMAGED. 4 Company Type AIRLINE or SUB- TENANT. CONCESSIONS CONSTRUCTION UNION. GOVERNMENT. TENANT. VENDOR CONTRACTOR. Last Name First Name Middle Name 5. Do you have any Last Name First Name Middle Name nicknames or aliases? Maiden/Alias 1. 6 NO YES Alias 2. Alias 3. Social Security Number: (9 digits, no dashes) (submission is voluntary, although failure 7 to provide it may delay or prevent completion of the security threat assessment). Date of Birth: Home Address: Daytime Telephone Number SSN: 8. City: State: Zip Code: Country: Current Mailing Address (if different from home address above)No Boxes: E-mail address (if applicable).

2 9. City: State: Zip Code: 10 Gender: Male Female Race: Asian Black Native American Unknown Caucasian/Latino 11 Height: FEET INCHES Weight: LBS. Natural Hair Color: Natural Eye Color: 12. Brown Black Blonde Red Gray White None Black Blue Brown Hazel Green Gray If at above address for less than 5 years, list previous address: 13. City of Birth State County and Country of Birth (country name and code): 14. Are you a US Citizen? NO YES Are you authorized to work by the Government of the United States? NO YES. Country of Citizenship: Certification of Birth Abroad, Form DS-1350, or 10 digit document number (no dashes): DS. Alien Registration Number or USCIS Number (Referred as ARN or INS No.) (9 digits, no dashes) : 15. Non-Immigrant Visa CONTROL Number (if applicable): I-94 Arrival/Departure Form Number (11 digits, no dashes) (if applicable): Passport Country: Passport Number: Passport Expiration Date: The Theinformation informationI have I haveprovided provided is true, complete, is true, complete,andand correct to the correct to best of myofknowledge the best my knowledgeand belief and is and and belief provided in goodinfaith.

3 Is provided good I faith. I. understand understandthatthata a knowing knowing and willful and false willful statement false can can statement be punished be punished by fine by or imprisonment fine or imprisonmentor bothor(see bothSection 1001 of1001. (see Section Title of 18 Title of the18 of United States the United Code).Code).. States IIauthorize authorizethe theSocial SocialSecurity SecurityAdministration Administration to release my Social to release Security my Social Number Security and fulland Number name toname full the Transportation Security Administration, to the Transportation Security Office of Intelligence Administration, andof Office Analysis (OIA), Attention: Transportation Threat Aviation AssessmentPrograms (TSA-10)/ Aviation and Credentialing Worker (TTAC), Program, Aviation Attention: 601 SouthPrograms 12th Street, Arlington, VA. (TSA-10)/ Aviation 16 Worker 20598. Program, I am 601 South the individual 12th the to whom Street, Arlington, information VA 20598.

4 Applies and wantI amthisthe individualreleased information to whom to the information verity that my SSN applies and Iwant is correct. knowthis that if I. information released to verity make any representation that I know thatismy SSN. false to is correct. obtain I know from information that ifSocial I make any representation Security records, I couldthat I know is by be punished false to obtain a fine information or imprisonment or from Social Security records, I could be punished by a fine or imprisonment or both. both. Signature: Date of Birth: SSN: Full Name: 10/04/2018. 01/26/2017 1. The Privacy Act of 1974, 5 552a (e) (3) Privacy Act Notice. *PRIVACY. Authority: 6 ACT. 1140, 46 Authority: NOTICE: 70105;. 49 C. 106,44936. 114, 114, 5103a, 40103(b)(3), authorizes 40113, 44903, the collection 44935. of this - 44936, 44939, and 46105; the Implementing information. Recommendations of the 9 / 11 of Purpose: The Department Commission HomelandAct of 2007,(DHS). Security 1520(121will Stat.)

5 444,biographical use the Public Law 110 - 53, Augustto information 3,conduct 2007); and a Executive Order 9397, security threat as amended. assessment to evaluate *your Purpose: The Department eligibility for the programof Homeland to whichSecurity(DHS) will use the Your you are applying. biographic information fingerprints and toassociated conduct a security threat information/biometrics will befingerprints provided to andFederal associated Bureau of information Investigation will (FBI). be provided for thetopurpose the Federal of Bureau comparing of Investigation(FBI). your fingerprints for to thethe purpose of comparing fingerprints in theyour FBI's fingerprints to other fingerprints Next Generation in the Identification (NGI). FBI's systemNextorGeneration Identification(NGI). its successor system or its systems (including successor civil, criminal, systems including and latent civil, criminal, fingerprint and latent fingerprint repositories). The may retain your FBI may retain yourand fingerprints fingerprints associatedand associated informationin information/biometrics in NGI.

6 NGI after afterthethe completion completion of this ofapplication and, while this application retained, and, while your fingerprints retained, your may continue to fingerprints maybe compared continue to be against comparedotheragainst fingerprints othersubmitted fingerprintsto orsubmitted retained byto NGI. or DHS will also retained transmit by NGI. the fingerprints DHS for enrollment will also transmit into the USfor the fingerprints - VISIT's Automated enrollment Biometrics into the US-VISIT's Identification System(IDENT).If Automated Biometrics you provide Identification your Social System (IDENT). Security If youNumber(SSN), provide your DHS may provide Social Security your name and Number SSN DHS. (SSN), to themay Social Security provide Administration(SSA). your name and SSN. to to compare the SocialthatSecurity information against SSA's Administration records (SSA) to ensure the to compare thatvalidity of the information. information against SSA's records to ensure the validity of your name and SSN.

7 *Routine Routine Uses: Uses:In This addition to those disclosures information may be shared generallywithpermitted underduring third parties 5 522a(b). course of the of Privacy Act,threat a security all or aassessment, portion of the employment records or information investigation, contained in this system or adjudication may be or of a waiver disclosed appealoutside requestDHS toasthe a routine extentuse pursuant to necessary to5 obtain 522a(b)(3). informationincluding with third pertinent parties to the during the course assessment, of a investigation, or security threat of adjudication assessment, employment your application or ininvestigation, accordance or adjudication with the routine of auses waiver or appealinrequest identified to the extent necessary the Transportation SecuritytoThreat obtain Assessment information pertinent Systemto(T- the assessment, STAS), DHS/TSA investigation, 002. Fororas adjudication long as yourof your application and fingerprints or in associated accordance with the routine information areuses identified retained in in NGI,the TSA.

8 Yoursystem of records information maynotice (SORN). be disclosed Badge #. DHS/TSA. pursuant002, Transportation to your consent orSecurity withoutThreat Assessment your consent System. Forby as permitted asthe long as youract privacy fingerprints of 1974 and and associated all applicableinformation/biometrics Routine Uses as may are retained in NGI, at be published your information any time in the may be disclosed federal register, pursuant includingtothe your consent Routine or without Uses for theyourNGIconsent systemasand permitted the FBI byblanket the Privacy Act ofUses. Routine 1974 and all applicable Routine Uses as may be published Disclosure: at any time Furnishing thisininformation the Federal Register, (including including your SSN) the Routine Uses for is voluntary; the NGI system however, if you doandnot theprovide FBI's Blanket Routine your SSN or Uses. any other information *requested, Disclosure:DHSF urnishing may be this information(including unable to complete your your SSN) is voluntary.

9 Application however,media for identification if you do not provide your SSN or any other information requested, DHS may be unable to complete your application for a security threat assessment. Chicago Airport System Photo ID Badge and ACCESS CONTROL Badge Holder Agreement I will comply with all airport and federal rules and regulations governing my ACCESS privileges to the Security Areas including the Secured Area, SIDA, Sterile Area and Air Operations Area; including my authority to authorize others to have ACCESS to these security areas as presented to me by the TSA approved SIDA Training Course, including: ID badges are not transferable and must be displayed on the outermost garment, above the waist and below the neck at all times. I understand that the badge is the property of the City of Chicago and must be surrendered upon demand, resignation, dismissal or suspension. I will not alter or deface the badge in any way, including punching holes in the badge or affixing stickers to the badge.

10 I must report any attempts to use an altered or expired badge. 17 I must challenge and/or immediately report any individual I find in the SIDA without proper authorization or who is not displaying a proper ID to my supervisor, the Chicago Police or Aviation Security, or any other entity charged with security responsibilities. I must immediately report a lost/stolen ORD or MDW ID badge to the Airport Communication Center. I understand that all vehicles, property and persons are subject to search by the TSA, Chicago Police Department and/or Aviation Security. I will return my badge to the Chicago Department of Aviation when ACCESS privileges in excess of 30 days are no longer required. SSN: I agree to abide by the City of Chicago Department of Aviation Ground Vehicle Operating Regulations. I understand that I am subject to fines and revocation of driving and/or badging privileges for violating regulations enforced by the Department of Aviation . When travelling When as aa passenger travelling as passenger,within I mustthe ,I the ACCESS must ACCESS Sterile the through Area Sterile Area through the TSA a TSA Passenger screening checkpoint, Screening includingcheckpoint Known Crew or Member Known Crew Member checkpoint checkpoints with anywith any accessible accessible propertyproperty I intend I intend to to carry onboard carry onboard theand the aircraft aircraft andinremain remain in theArea the Sterile Sterile Area after after entering.