Authorized Signer Application Form - Phoenix Sky Harbor ...

PHOENIX SKY HARBOR INTERNATIONAL AIRPORTCOMPANY APPLICATION FOR GROUND TRANSPORTATIONONE APPLICATION PER AUTHORIZED REPRESENTATIVEThis form must be completed and signed in the presence of a Notary Public or a Security Badging office representative.COMPANY NAME: ______________________________________________________________________________________________MAILING ADDRESS: _____________________________________________________________________________________________STREET / PO BOX CITY STATE ZIPLOCAL ADDRESS: _______________________________________________________________________________________________(If different than above) STREET CITY STATE ZIPCOMPANY PHONE NO.: (______) ________ – ________________ COMPANY FAX NO.: (______) ________ – ________________COMPANY E-MAIL ADDRESS: ____________________________________________________________________________________NAMES AND SIGNATURE OF COMPANY REPRESENTATIVE AUTHORIZED TO CHANGE ACCESS LISTS OR AUTHORIZE:(mark ‘x’) BADGES ONLY ■ KEYS ONLY ■ BADGES AND KEYS ■_______________________________________________________ ______ - ______ - __________ ____________________/ /REPRESENTATIVE NAME (PRINT) SOCIAL SECURITY NUMBER DATE OF BIRTH_______________________________________________________REPRESENTATIVE SIGNATURE________/________/________DATEREASON ACCESS IS REQUIRED: _________________________________________________________________________________________________________________________________________________________________________________________________WE ARE AWARE AND AGREE TO COMPLY WITH THE FOLLOWING:1. ALL COMPANY EMPLOYEES REQUIRING A PHOENIX SKY HARBOR SECURITY CREDENTIAL MUSTCOMPLETE AND PASS A STA AND CRIMINAL HISTORY RECORD CHECK PRIOR TO THE ISSUANCE OF THE BADGE.2. THE COMPANY IS RESPONSIBLE FOR THE MONITORING, AND RETURN OF ALL ISSUED BADGES AND KEYS TOTHE CITY OF PHOENIX SECURITY BADGING OFFICE.3. THE COMPANY WILL IMMEDIATELY NOTIFY THE BADGING OFFICE IF A BADGE OR KEY IS LOST, STOLEN ORNOT RETRIEVED FROM A TERMINATED EMPLOYEE.Failure to comply with any of above could result in the revocation of your company’s privilege to have access to theAir Operations Area. Your company further agrees that it will reimburse the City of Phoenix Aviation Department forany fines levied against it as a result of violations committed by your company, its employees or representatives.__________________________________________ ________________________________________ _______ /_______/_______AUTHORIZED SIGNATURE POSITION WITH COMPANY DATE(Existing Authorized Signer or Company Head if new company)This form was signed before me this _________ day of____________, 20_____._______________________________________________SignatureNotary Public in and for:County:__________________________________State: ___________________________________My commission expires:______ day of ___________________ 20 ______AVIATION DEPARTMENT AUTHORIZATION:C.H.R.C. CertificationCompany No.: _______________________________COMMENTSVerification Letter on file: YES / NO _________________________________________________Ops Approval on file: YES /NO _________________________________________________Insurance on file: YES / NO / NA _________________________________________________B&P C.U.P. on file: YES / NOData Entered By: ____________________________ Date: ______/______/______Supervisor Approval: _________________________ Date: ______/______/______CHRC Case #: _____________________________121-132D Rev. 10/2010

The City of Phoenix Aviation Department welcomes you to Phoenix Sky Harbor International Airport. With the approval of this application, youwill be joining a team that is dedicated to ensure the security of Sky Harbor International Airport. We, in the Aviation Department will provideall the tools and training that will assist you in being an integral part of our Security organization.Whether you have been doing business at the airport for years or you are a new company about to conduct business on the airport, andrequire unescorted access to any part of the Air Operations Area, SIDA, or designated public areas, please read the following instructionscarefully as a number of procedures have changed and might affect how you conduct your airport business.• A STA and fingerprint-based Criminal History Records Check (CHRC) must be completed and confirmation received that the individual has notbeen convicted or found not guilty by reason of insanity, in the last ten years, of the crimes listed and acknowledged by the individual,BEFORE a security credential can be issued. The results will take approximately one week.• Corporate Applications must be completed and submitted one week prior to submitting employees for badging and Security Class. Theauthorized signer’s must have a STA and Criminal History Records Check completed as per the above statement.• All fingerprinting will be completed at the Badging Office between Terminal 2 and 3.The fee for fingerprinting and initial security credential is $39 per applicant and is subject to change without notice and is non-refundable.Renewal badge fee is $10 and a replacement fee of $10 is charged for all lost, stolen, damaged security badges.Cash, checks, cashier checks, and credit cards are accepted.Checks are payable to: “City of Phoenix - Aviation Department.”REQUIRED COMPANY PAPERWORK:1 Letter of Verification:Your company must submit a letter of verification from the City of Phoenix, Airline, Airport Tenant or Contractor with whom you havea contract. The letter must outline:• Scope of work to be performed;• Specific location of the work;PHOENIX SKY HARBOR INTERNATIONAL AIRPORTCOMPANY APPLICATION FOR GROUND TRANSPORTATIONONE APPLICATION PER AUTHORIZED REPRESENTATIVE• Start and finish dates of the project. The Badging Office will not accept “Ongoing” as a completion date.2. Completed “Company Application for Ground Transportation"form. Air Operations Area Access” Form.On reverse side is the application. This form contains all the pertinent information that is required on your company. It is very importantthat the information be correct and any changes be relayed to the Aviation Department as soon as possible.Please Note:The form requires your company to delegate specific representatives of your firm to be named as authorized signers for airport securitybadges. You can have as many authorized signers as you wish, simply complete one of these forms for EACH authorized signer. Theywill become the official contact when it comes to security matters. These individuals must complete an individual application for abadge and have a STA and Criminal History Records Check completed prior to approval of the Company’s application.ONLY THESEINDIVIDUALS WILL BE ALLOWED TO SIGN YOUR EMPLOYEE’S BADGE APPLICATION FORM. ALL SIGNATURES MUST BE ORIGINAL.The Company management officer, who is signing the corporate application form, must do so in front of a notary, or in the presence ofbadging office personnel.3. Vehicles:• If vehicle access to the Air Operations Area is required, your company requires a certificate of insurance naming the City ofPhoenix, Aviation Department, as the Certificate Holder and Additional insured in the amount of $5,000,000 for automobileliability or excess liability. The policy must show an expiration date and policy number. It cannot be a "binder".• Each vehicle entering the Air Operations Area must have at least a company logo on both sides. Logos must be a minimum of 12"in diameter with 4” lettering against a contrasting background for easy identification.• Each driver must have an unescorted access Sky Harbor Badge, and passed the Airfield Drivers Course.If vehicle access to the Air Operations area is required and no insurance has been registered with the Aviation Department, a vehiclemust escort your vehicle, which has been approved Air Operations Area access and a driver who has an airfield driver’s permit.Once all the documentation has been received and approved by the Aviation Department, applications for unescorted access badges will beaccepted.If you have any questions concerning the above, contact the Aviation Department, Badging Office at 602-273-2036.(Application on reverse side)