AGREEMENT between BROWARD COUNTY and Cummings ...

Badging Requirements and Ramp Driving Privileges
Exhibit 2
Page 339 of 379
SOCIAL SECURITY INFORMATION
FOR PURPOSES OF UNESCORTED ACCESS IN STERILE AND SECURE AREAS
FULL Name: _______________________________________________________
(print first, middle, last)
Company Name: ____________________________________________________
Social Security Number: ______________________________________________
(all nine numbers)
I authorize the Social Security Administration to release my Social Security Number and
full name to the Transportation Security Administration, Office of Transportation, Office of
Transportation Threat Assessment and Credentialing (TTAC), Attention: Aviation Programs
(TSA-19)/Aviation Worker Program, 601 South 12 th Street, Arlington, VA 20598.
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 representation that I know is false to obtain
information from Social Security records, I could be punished by a fine or imprisonment or
both.
I refuse to submit my Social Security Number and understand that doing so may delay
or prevent completion of a Security Threat Assessment which is required for me to obtain an
airport ID/access media according to federal regulations.
Signature: ___________________________________ Date: ______________________
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