APPLICANT INFORMATION THIS SECTION MUST BE …

1 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.

2 DATE (MM/DD/YYYY)STATE / COUNTRYP assport State Driver LicenseState IDOther: / / LIST ALL ALIASES USED OR WRITE NONE COMMENTSMANDATORY CRIMINAL HISTORY QUESTIONNAIRE this SECTION must BE COMPLETED BY APPLICANTW ithin the past ten (10) years, have you been convicted or found guilty by reason of insanity of any of the following offenses, including convictions which were later dismissed, reduced or expunged? Please mark the appropriate Yes or No box for EACH of the convictions listed NoForgery of certificates, false markings of aircraft, and other aircraft registration violationsYes NoUnlawful possession, use, sale, distribution or manufacture of an explosive or weaponYes NoInterference with air navigationYes NoViolence at international airportsYes NoImproper transportation of a hazardous materialYes NoRape or aggravated sexual abuseYes NoAircraft piracyYes NoArmed or felony unarmed robberyYes NoInterference with flight crew members or flight attendantsYes NoFelony involving aggravated assaultYes NoCommission of certain crimes aboard an aircraft in flightYes NoDistribution of or intent to distribute.

3 A controlled substanceYes NoDestruction of an aircraft or aircraft facilityYes NoFelony involving a threatYes NoFelony involving willful destruction of propertyYes NoConveying false INFORMATION and threatsYes NoFelony involving possession or distribution of stolen propertyYes NoFelony involving briberyYes NoCarrying a weapon or explosive aboard an aircraftYes NoFelony involving dishonesty, fraud or misrepresentationYes NoAssault with intent to murderYes NoEspionageYes NoMurderYes NoTreasonYes NoKidnapping or hostage takingYes NoSeditionYes NoExtortionYes NoFelony involving burglaryYes NoFelony arsonYes NoFelony involving theftYes NoLighting violations involving transporting controlled substancesYes NoFelony involving importation or manufacture of a controlledsubstanceYes NoAircraft piracy outside the special aircraft jurisdiction of the United StatesYes NoFelony involving illegal possession of a controlled substancepunishable by a maximum term in prison of more than 1 yearYes NoUnlawful entry into an aircraft or airport area that serves aircarriers or foreign air carriers contrary to established securityrequirementsYes

4 NoConspiracy or attempt to commit any of the aforementioned criminal acts_____INITIALSI 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).(424)646-5500 LAX SECURITY CREDENTIALS SECTION7333 WORLD WAY WEST, 1ST FLLOS ANGELES, CA 90045 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.

5 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 BADGE HOLDER RESPONSIBILITIES AS A BADGE HOLDER YOU must :xDisplay your badge at all times while in a restricted areaxWear your badge on your upper body and on your outermost garmentxChallenge anyone not wearing a badge in a restricted areaxRemain with anyone you are escorting at all timesxReport emergencies by calling Airport Police at (424) 646-7911 available anytimexNever piggyback or allow others to piggyback through secured access pointsxNever share your badgexNever deface or alter your badgeYOU must RETURN THE BADGEAll security ID media issued by the LAX Security Credentials SECTION are the property of the City of Los Angeles and must be returned upon expiration, separation of employment (for any reason)

6 , when job function no longer requires an airport-issued security badge and/or upon demand from Los Angeles World Airports. Any misuse or willful failure to return a security badge is punishable by criminal misdemeanor prosecution. Security badges are non-transferable and must be used only by the person to whom they are AIRPORT SECURITY INFORMATIONNo person issued a security badge may divulge any INFORMATION concerning an act of unlawful interference with civil aviation if such INFORMATION is likely to jeopardize the safety of domestic or international aviation or regarding any airport or airport tenant s security system to unauthorized persons WKDW PD\ WDPSHU LQWHUIHUH FRPSURPLVH PRGLI\ RU FLUFXPYHQW DQ\ VHFXULW\ V\VWHP LQ DFFRUGDQFH ZLWK &)5 0 D BADGE DISPLAY AND CHALLENGE RESPONSIBILITIES The Transportation Security Administration (TSA) approved security program for the Los Angeles International Airport (LAX)

7 Requires each person issued an airport security photo identification badge be made aware of his or her responsibilities regarding the privileges of access to restricted areas of the airport. All persons within the restricted Air Operations Area of the airport are required to display their badge, as described in the Los Angeles International Airport (LAX) Comprehensive Airport Security Manual, unless accompanied by an appropriately badged escort. Each employee who has been issued a security badge is responsible for challenging any individual who is not properly displaying an airport approved badge. Any person who is not properly displaying a valid security badge must be immediately reported to Airport Police. NOTIFY AIRPORT POLICE AT (424) AREA DRIVER - RAMP / SERVICE ROADS All restricted area drivers shall possess and carry a valid driver s license while driving on the Air Operations Area.

8 Each driver is required to receive 8 hours of practical (behind the wheel) driver s training on the Air Operations Area and successfully pass the written examination administered by the LAX Security Badge AND SAFETY ENFORCEMENT (SAFE) PROGRAMAs outlined in the LAX SAFE Program, an individual receiving a SAFE program citation must promptly respond to the SAFE Program administrator. LAX Security Badge database INFORMATION may be shared with the SAFE Program administrator to assist in the timely notification to the citation holder and their employer(s). For INFORMATION on the LAX SAFE Program, please call (424) 646-5889. INFORMATION is also available online at KWWS VER ODZD RUJ XQGHU WKH $SSOLFDQW WDE PRIVACY ACT NOTICE & EMPLOYEE CERTIFICATION this SECTION must BE COMPLETED BY APPLICANTAPPLICANT NAME (PRINT)DATE OF BIRTH (MM/DD/YYYY)// APPLICANT SIGNATURESOCIAL SECURITY NUMBERx--Authority: 6 1140, 46 70105; 49 106, 114, 5103a, 40103(b)(3), 40113, 44903, 44935-44936, 44939, and 46105; the Implementing Recommendations of the 9/11 Commission Act of 2007, 1520 (121 Stat.)

9 444, Public Law 110-52, August 3, 2007); and Executive Order 9397, as amended. Purpose: The Department of Homeland Security (DHS) will use the biographic INFORMATION to conduct a security threat assessment. Yourfingerprints and associated INFORMATION will be provided to the Federal Bureau of Investigation (FBI) for the purpose of comparing your fingerprints to other fingerprints in the FBI s Next Generation Identification (NGI) system or its successor systems including civil, criminal, and latent fingerprint repositories. The FBI may retain your fingerprints and associated INFORMATION in NGI after the completion of this application and, while retained, your fingerprints may continue to be compared against other fingerprints submitted to or retained by NGI.

10 DHS will also transmit your fingerprints for enrollment into US-VISIT Automated Biometrics Identification System (IDENT). If you provide your Social Security Number (SSN), DHS may provide your name and SSN to the Social Security Administration (SSA) to compare that INFORMATION against SSA records to ensure the validity of the INFORMATION . Routine Uses: In addition to those disclosures generally permitted under 5 522a(b) of the Privacy Act, all or a portion of the records or INFORMATION contained in this system may be disclosed outside DHS as a routine use pursuant to 5 522a(b)(3) including with third parties during the course of a security threat assessment, employment investigation, or adjudication of a waiver or appeal request to the extent necessary to obtain INFORMATION pertinent to the assessment, investigation, or adjudication of your application or in accordance with the routine uses identified in the TSA system of records notice (SORN)