Kahului Airport NEW BADGE APPLICATION - Hawaii

1 Rev 3/16/2021 Page 1 Kahului Airport NEW BADGE APPLICATION Choose PIN (No 0) 9 # BADGE TYPE SIDA (Security Identification Display Area) STERILE AOA (General Aviation) PUBLIC: Greeter Porter Baggage SECTION 1: APPLICANT INFORMATION Handwritten applications will be rejected. Complete all applicable sections. Incomplete forms will be rejected. FULL LEGAL NAME (As stated on government issued identification) LAST NAME FIRST NAME MIDDLE NAME ALIASES (Include all previous names, married, maiden) ALIAS 1 (Last Name, First, Middle) ALIAS 2 (Last Name, First, Middle) SOCIAL SECURITY NUMBER DATE OF BIRTH (mm/dd/yyyy) RACE/ETHNICITY (For fingerprint purposes) American Indian Asian Black White Other GENDER Male Female Other HEIGHT ( ) WEIGHT (lbs.)

2 EYE COLOR HAIR COLOR PLACE OF BIRTH (STATE) PLACE OF BIRTH (COUNTRY) COUNTRY OF CITIZENSHIP MAILING ADDRESS APT # CITY STATE ZIP CODE DAYTIME PHONE # E- MAIL ADDRESS COMPANY NAME FOR PASS AND ID OFFICE USE ONLY FORMS OF IDENTIFICATION List A: List B: List C: No. Exp: No. Exp: BADGE INFORMATION Visible ID: Notified : Pulled: STA: _ Green Red BADGE #: _ CHRC: Q DQ Issued: SIDA Training Date: Deactivate: Rap Back: Exp: _ Rap Back Exp: Signatory Escort Temp NHB Keys BC14 CBP1 CBP2 LOST BADGE (Report Date) LOST BADGE (Report Date) Airport Security Manager s Approval 3rd LOST BADGE : Replacement Visible ID: Replacement Visible ID: Rev 3/16/2021 Page 2 SECTION 2.

3 COMPANY INFORMATION SIGNATORY AUTHORIZATION MUST be completed by AUTHORIZED SIGNATORY of the sponsoring company. Type or print legibly or APPLICATION will be rejected APPLICANT S FULL LEGAL NAME (Last, First, Middle) BADGE TRANSACTION Signatory Initial Date TA Initial New New Hire Temporary BADGE Renew I, as the Authorized Signatory, attest to the following: 1. The named applicant on this APPLICATION is employed with the company I represent. My company is this applicant s sponsor. This applicant acknowledges their security responsibilities under 49 CFR (a).

4 2. A specific need exists for this applicant to obtain the requested ID Media BADGE , its specific unescorted access authority and requested BADGE designations. 3. I have reviewed this APPLICATION for accuracy and legibility and have verified the employment eligibility of the applicant. 4. I have reviewed the original documents which are the source of the information provided in Section 1 of this APPLICATION and find that the documents appear genuine. The information from those original documents was correctly entered in Section 1 of the APPLICATION . On behalf of the company, I further acknowledge the following responsibilities as the Authorized Signatory: 1.

5 Immediately notify Pass & ID Office or Airport Security Coordinator (during business hours), or Airport Security Services (24/7) to deactivate the employee s BADGE if any of the following occurs: suspension, separation from company, resignation, termination for any reason, transfer, lay off, conviction of a disqualifying felony, or for any other reason that the BADGE is no longer needed or if there is any reasonable belief that the person may present a danger to the Airport , civil aviation, employees of the Airport , the travelling public, and/or Airport users.

6 2. Ensure that Airport -issued ID Media, including expired badges, are returned to the OGG Pass & ID Office within five business days of notification to deactivate since the company, as the sponsor, is responsible for the accountability of the BADGE . 3. If this BADGE is not returned within five business days of notification to deactivate, my company, as sponsor, will pay applicable unrecoverable BADGE fees on time. I understand that my company s agreement, as sponsor, to be responsible for such charges and fees is a material condition to the Airport s issuance of the BADGE , and that without such an agreement from the sponsor, the Airport would not issue a BADGE to the applicant.

7 4. Ensure that no Airport -issued ID Media are transferred to or used by any person other than to whom they were issued. 5. Understand that the company may be responsible for their employees infractions and may be subject to fines and/or civil penalties. COMPANY / SIGNATORY INFORMATION COMPANY NAME DEPARTMENT AUTHORIZED SIGNER (Print) DATE: (Valid for 30 days after signed and dated) AUTHORIZED SIGNER (Signature) E- MAIL ADDRESS: PROJECT DURATION / CONTRACT END DATE: PHONE NUMBER: GENERAL CONTRACTOR / PROJECT NUMBER Pass & ID Office Trusted Agent: Rev 3/16/2021 Page 3 APPLICANT S FULL LEGAL NAME: (Last, First, Middle) SECTION 3.

8 TSA CRIMINAL HISTORY QUESTIONNAIRE -49 CFR MUST be completed by the applicant Have you ever been convicted (under Federal Law deferred adjudication or similar outcome is considered a conviction), entered a plea of nolo contendere or been found not guilty by reason of insanity, of any of the crimes listed below in the last 10 years? Please check the appropriate box next to each crime description. List of Crimes YES NO List of Crimes YES NO Forgery of certificates, false marking of aircraft, and other aircraft registration violation (49 U. S. C. 46306) Unlawful possession, use, sale, distribution, or manufacture of an explosive or weapon.

9 Interference with air navigation (49 U. S. C. 46308) Extortion Improper transportation of a hazardous material (49 U. S. C. 46312) Armed or felony unarmed robbery Aircraft piracy (49 U. S. C. 46502) Distribution of, or intent to distribute, a controlled substance Interference with flight crew members or flight attendants (49 U. S. C. 46504) Felony arson Commission of certain crimes aboard aircraft in flight (49 U. S. C. 46506) Felony involving a threat Carrying a weapon of explosive aboard aircraft (49 U. S. C. 46505) Felony involving: YES NO Conveying false information and threats (49 U.)

10 S. C. 46507) Willful destruction of property Aircraft piracy outside the special aircraft jurisdiction of the United States (49 U. S. C. 46502(b)) Importation or manufacture of a controlled substance Lighting violations involving transporting controlled substances (49 U. S. C. 46315) Burglary Unlawful entry into an aircraft area that serves air carriers of foreign air carriers contrary to established security requirements (49 U. S. C. 46314) Theft Destruction of an aircraft or aircraft facility (18 U. S. C. 32) Dishonesty, fraud or misrepresentation Murder Possession or distribution of stolen property Assault with intent to murder Aggravated Assault Espionage Bribery; or Sedition Illegal possession of controlled substance punishable by a maximum term of imprisonment of more than one (1) year Kidnapping or hostage taking Violence at international airports (18 U.