AGREEMENT between BROWARD COUNTY and Cummings ...

Badging Requirements and Ramp Driving Privileges
Exhibit 2
Page 337 of 379
APPLICATION FOR IDENTIFICATION CARD OR SECURITY BADGE TRANSACTION
Sponsor
Company: __________________________________________________
Contracted
Company: __________________________________________________
Employee Full Name:
__________________________________________________________
(First) (Middle) (Last)
Job Title:___________________________________________________
Original FLL Badge or ID _____
Replacement for: Renewal ______ Damaged ______ Lost ______
Name Change ______ Add Customs ______ Add Escort ______
BADGE TYPE: (check one only)
___ SIDA
Concourse Tenants: ____ Gate 100 & Employee Access SIDA
____ Concourse & Ramp Access
Date of Birth:________________________________________________
Employment Date:___________________________________________
___ Sterile Concourse
___ General Aviation
___ Government
____ ID Card (Only For Concourse Access)
____ LEO ____ CLEO (with TSA approval)
Employee Signature:
__________________________________________________________
EMPLOYEE AFFIDAVIT:
The information I have provided is true, complete, and correct to the
best of my knowledge and belief and is provided in good faith. I
understand that a knowing and willful false statement can be
punished by fine or imprisonment or both (Section 1001 of Title 18 of
the United States Code).
___ Construction
Requested Expiration Date: ______________________________________
(i.e. contract completion date; INS work authorization; etc.)
Signature:
_____________________________________________________________
Authorized Signatory Signature
Date
Note: If the employee does not obtain their badge within 30 days from the
date of this application, a new application, and possibly a new Criminal
History Records Check, will be required.
AFFIDAVIT: This applicant acknowledges that the Transportation Security Administration (TSA) has determined that a withheld
adjudication, whether through a guilty plea or a plea of nolo contendre (no contest), constitutes a conviction for the purpose of
unescorted access to the AOA (49 CFR Part 1542). I also accept that upon receipt of a directive from the TSA or a modification to the
regulation, my unescorted access to the secure area of the Airport may be denied or revoked.
BILLING (allowable only to companies authorized by BCAD Finance Department))
______________________________________________________________
Authorized Signatory Signature for Billing
___________________________________________
Date
ID PROCESSING: Original Badge……………..…… ……..….….….....$15.00 Payment: Cash $_____________
Renewal or Replacement (old badge returned).…$15.00
Transportation Security Clearinghouse (STA)…… $6.00 Check $_________ No.__________
Lost / Stolen………………………...........................$50.00
Unreturned Badge ……... ……....…..…… ..……. $100.00 Billing $_____________
Trusted Agent Accountability:
Intake Initials:
__________________ Date: ______________
Data Entry Initials: ________________ Date: ______________ COLOR: __________________ BADGE #:__________________
Badge Issuer Initials: ______________ Date: ______________
Released By: ___________________ Received By: ________________________________________
Date: ______________________
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
Administrator of the Transportation Security Administration or the Secretary of Transportation. Unauthorized release may result in civil
penalty or other action. For U.S. government agencies, public disclosure is governed by 5 U.S.C. 552 and 49 CFR Parts 15 and 1520.
5-1-10 Revision Page 6