Barkley Regional Airport

Badge Application Form Instruction Sheet

Please follow instructions below when filling out this form.

Please fill this application out on your computer, hand written applications WILL NOT BE ACCEPTED. If you do not have a computer you may come to Barkley Regional Airport and we will assist you. THIS APPLICATION MUST BE DONE IN WORD FORMAT. DO NOT SCAN IN PDF OR OTHER APPLICATIONS.

Fill in all blanks within the application.

If a field does not apply to you please put N/A in that field.

When you have completed this application save it. To save Please follow instructions below:

To save,

Click FILE in the upper left corner of your screen. Then scroll down to save and click Save. Then rename your file as your name. Look to see where your file is going to be saved so you know where to find it later. Then click save on the pop up window.

DO NOT SIGN THE APPLICATION. The application will be signed at the badging office when you come in to do your photo for your badge.

You do not need to fill in the signatory block unless you have been to the badging office and completed the required signatory training.

ALL BADGE APPLICANTS WILL HAVE TO GO THROUGH DRIVERS TRAINING WITH THE DIRECTOR OF OPERATIONS BEFORE YOUR BADGE WILL BE ISSUED.

After you have saved the application go into your email and attach the completed application to an email and send it to badge@barkleyregional.com

You will be contacted by phone when your background has been completed and you are ready to be badged.

Again, you will sign your application when you come in for your Photo for your badge.

Badging hours Vary Monday – Sunday. For an appointment contact Ronnie Harvell at rharvell@barkleyregional.com or call (270)744-0521.

Please be aware, you will only have 30 days to come and get your badge from the time you are called to come and have your photo made. After that 30 days if you have not come and gotten your badge, YOU WILL BE REVOKED and will have to wait 30 more days before you can reapply for a badge.

When you come in to sign your application and get your photo taken for your badge we would prefer you bring either CURRENT DRIVERS LICENSE AND BIRTH CERTIFICATE OR BRING YOUR CURRENT PASSPORT. However, if you do not have those, the following are acceplable forms of ID:

LIST OF ACCEPTABLE DOCUMENTS All documents must be UNEXPIRED Employees may present one selection from List A or a combination of one selection from List B and one selection from LIST C
LIST A Documents that Establish Both Identity and Employment Authorization	LIST B Documents that Establish Identity	LIST C Documents that Establish Employment Authorization
U.S.Passport or U.S. Passport card	Drivers license or ID card issued by a state or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address	1. A Social Security account number card, unless the card includes one of the following restrictions: (1) NOT VALID FOR EMPLOYMENT (2) VALID FOR WORK ONLY WITH INS AUTHORIZATION (3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION
Permanent Resident Card or Alien Registration Receipt Card (Form I-551)
Foreign passport that contains a Temporary I-551 stamp or temporary I-551 printed notation on a machine-readable immigrant visa	ID card issued by federal, state, or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address	2. Certification of birth abroad issued by the Department of State (Form FS – 545)
Employment Authorization Document That contains a photograph (Form I-766)	School ID card with a photograph	3. Certification of report of birth issued by the department of state (Form DS – 1350)
For a nonimmigrant alien authorized to work for a specific employer because of his or her status: Foreign passport: and Form I-94 or Form I-94A that has the following: The same name as the passport; and An endorsement of the alien’s nonimmigrant status as long as that period of endorcement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form.	Voters registration card	4. Original or certified copy of birth certificate issued by a state, county, municipal authority, or territory of the United States bearing and official seal
U. S. military card or draft record
Military dependents ID card
U. S. Coast Guard merchant Mariner card
Native American tribal document	5. Native American tribal document
Drivers license issued by a Canadian government authority	6. U. S. citizen ID card (Form I – 197)
Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form I-94 or Form I-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI	For persons under age 18 who are unable to present a document listed above:	7. Identification card for use of resident citizen in the United States (Form I – 179)
10. School record or report card
11. Clinic, doctor, or hospital record	8. Employment authorization document issued by the Department of Homeland Security
12. Day-care or nursery school record
Illustrations of many of these documents appear in part eight of the handbook for employers (M – 274). Refer to section 2 of the instructions, titled “Employer or With authorized Representative Review and Verification,” for more information about acceptable receipts.

Form I – 9 03/08/13 N	Page 9 of 9

All information is to be typed. If certain data is not applicable, enter “NA” in the space provided.

SSN and Date of Birth are required.

Name:	Date of Birth:
Last	First	Middle

Current Address:	SSN:
Street

Phone #
City	State	Zip

Aliases (AKA) / Maiden Name	Male	Female

Height:	Weight:	Eyes:	Hair:	Race:

Employer:

Signatory Printed Name:

Signatory Signature	Signatory Email	Applicant Email

Place of Birth:
City	State/Providence	Country

Citizenship:	Country Issuing Passport:
Passport #	Alien Registration #

Certificate of Birth Abroad:

This section to be completed by Airport Authority Staff.

Date of Fingerprint/CHRC Clearance:	Findings:
Findings By:

Date of STA/Background Clearance:	Findings:
Findings By:

ID Badge Issue Date:	Badge #	Issuing T/A:

Badge Authorized Areas:	Badge Expiration Date:	12/31/

PG 1

Badge Issuance Tasking Checklist

Collect and transmit the biographical and biometric information used in the CHRC/STA

Name of T/A	Date
Signature of T/A

Authorize the issuance of Identification Media

Name of T/A	Date
Signature of T/A

PG 2

Fingerprint Application – Disqualifying Criminal Offenses

Below is a list of Disqualifying Criminal Offenses for Unescorted Access to Security Identification Display Areas (SIDA) at Barkley Regional Airport.

Disqualifying Criminal Offenses: An individual has a disqualifying criminal offense if the individual has been convicted, or found not guilty by reason of insanity, or any of the disqualifying crimes listed below in any jurisdiction during the 10 years before the date of the individual’s application for unescorted access authority, or while the individual has unescorted access authority. The disqualifying criminal offenses are as follows:

Forgery of certificates, false making of aircraft, or other aircraft registration violations, 49 U. S. C. 46306

Interference with air navigation, 49 U. S. C. 46308

Improper transportation of hazardous material, 49 U. S. C. 46312

Airport Piracy, 49 U. S. C. 46502

Interference with flight crew members or flight attendants, 49 U. S. C. 46504

Commission of certain crimes aboard aircraft in flight, 49 U. S. C. 46506

Carrying a weapon or explosive aboard aircraft, 49 U. S. C. 46505

Conveying false information in threats, 49 U. S. C. 46507

Airport piracy outside the special aircraft jurisdiction of the United States, 49 U. S. C. 46502(b)

Lighting violations involving transporting controlled substances, 49 U. S. C. 46315

Unlawful entry into an aircraft or airport area that serves air carriers or foreign air carriers contrary to establish security requirements, 49 U. S. C. 46314

Destruction of an aircraft or aircraft facility, 18 U. S. C. 32

Murder

Assault with intent to murder

Espionage

Sedition

Kidnapping or hostage taking

Treason

Rape or aggravated sexual abuse

Unlawful possession, use, sale, distribution, or manufacture of an explosive weapon

Extortion

Armed or felony armed robbery

Distribution of, or intent to distribute, a controlled substance

Felony arson

A felony involving a threat

Felony involving:

Willful destruction of property;

Importation or manufacture of a controlled substance;

Burglary;

Theft;

Dishonesty, fraud, or misrepresentation;

Possession or distribution of stolen property;

Aggravated assault;

Bribery; or

Illegal possession of a controlled substance punishable by a maximum term of imprisonment of more than one year

Violence at international airports, 18 U. S. C. 37

Conspiracy or attempt to commit any of the criminal acts listed in this paragraph

PG 3

Federal regulations under 49 CFR 1542.209(I) impose a continuing obligation for you to disclose to the airport operator within 24 hours if YOU are convicted of any disqualifying criminal offense that occurs while you have unescorted access authority.

The information I have provided on this application is true, complete, and correct to the best of my knowledge and belief and is provided in good faith. I understand that knowingly and/or willfully giving a false statement on this application can be punished by a fine, imprisonment, or both.

(See section 1001 of Title 18 United States Code).

Release of Information

“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-10)/Aviation Worker Program, 601 S. 12th 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 representations that I know is false to obtain information from Social Security Records, I could be punished by a fine or imprisonment, or both.”

Privacy Act Notice

Authority 49 U. S. C. § 114, 44936 authorizes the collection of this information.

Purpose: The Department of homeland security (DHS) will use the biographical information to conduct a security threats assessment to evaluate your eligibility for the program to which you are applying. Your fingerprints and associated information/biometrics 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 system or its successor systems (including civil, criminal, and latent fingerprint repositories). The FBI may retain your fingerprints and associated information/biometrics 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. DHS will also transmit the fingerprints for enrollment into the U. S.-VISIT’s 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’s records to ensure the validity of your name and SSN.

Routine uses: This information may be shared 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, and adjudication of your application or in accordance with the routine uses identified in the Transportation Security Threat Assessment System (T-STAS), DHS/TSA 002. For as long as your fingerprints and associated information/biometrics are retained in NGI, your information may be disclosed pursuant to your consent or without your consent as permitted by the Privacy Act of 1974 and all applicable Routine Uses as may be published at any time in the Federal Register, including the Routine Uses for the NGI system and the FBI’s Blanket Routine Uses.

Disclosure: Furnishing this information (including your SSN) is voluntary; however, if you do not provide years SSN or any other information requested, DHS may be unable to complete your application for identification media.

PG 4

AIRPORT SECURITY

ID BADGE ISSUANCE

ASSURANCES (AOA)

The undersigned agrees to comply with all Airport, FAA, and Transportation Security Administration regulations pertaining with being issued and displaying and Airport Authority ID badge for the purpose of gaining unescorted access to and working within areas identified by the Airport Authority as a Security Identification Area (SIDA). I understand and agree that:

I must carry my AOA ID badge on my person while in the AOA of the airport and produce my AOA ID badge on request.

I will not permit any and badge/unauthorized person or vehicle to enter a secure or AOA area of the airport.

I will immediately report any un-badged/unauthorized person or vehicle I see in a secure or AOA area to an Airport Authority Law Enforcement Officer, Airport Administration, or Midwest aviation.

I will escort any and unbadged personnel that requires business within the AOA and keep them within a controlled range for the duration of their entry into the AOA.

Airport law enforcement may be contacted at (270) 744-0521 EXT 140 or by calling (270) 744-0521 and speaking to the Airport Administration Office.

I will not discuss SSI which is Sensitive Security Information which includes personal information, security incidents, and/or airport security measures with anyone without a need to know basis.

I will not allow a person or cause a person to circumvent any airport security measure. If I observe any activity which violates an airport security measure, I will contact the Airport Security Coordinator’s at (270) 564-7502 or (270) 445-1280.

I will immediately report to Airport Security if my ID badge is lost or stolen. I agree to pay a $25 fee to the Airport Authority for a replacement ID badge.

Should my ID badge become damaged, I will notify the Director of Airport Security and request a replacement ID badge at no charge. I am aware I must turn in my damaged ID badge before I can be issued a replacement.

I understand and agree that my failure to comply with these assurances as well as Airport Authority, FAA, and Transportation Security Administration security regulations will result in my ID badge being revoked and my AOA access privileges being terminated.

I will not drive or walk away from an opened gate/door and will stay with the gate/door until it is closed/secure.

By signing below I agree to comply with the Barkley Regional Badge Issuance Assurances as well as agree to the Release of Information and Privacy Act Notice. I Give my consent for Barkley Regional Airport Authority or its employees to run or use any information necessary for me to be cleared for the proper background checks to be issued an airport ID Badge. I agree that all information I have provided is true and accurate to the best of my knowledge and understand that any false information may result in criminal charges or failure for me to be issued my Barkley Regional Airport Identification Media.

Applicant’s Printed Name	Applicant’s Employer
Applicant’s Signature	Date
Issued ID Badge Number	ID Issuer’s Signature

PG 5