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ABILENE
REGIONAL AIRPORT
CITY OF ABILENE TEXAS

Abilene Regional Airport Security

Badge Application/Renewal
Please print clearly in ink.

Bad d nly:

Current Badge #:

I currently have possession of my badge ___Yes___No

Ifyou answered “No", call 325-676-6369 immediately to reporl your lost/stolen badge.
Review and update all information below.

New Badge Applicant:

Brudtn Chuon-'1
Legal Name: Han@
First Middle
Last

Other Name(s) Used:

Last First Middle

Male: X Female: Birthdate: 121h7/2006

MMMDD/YYYY

Birth:_\ Jni+cd
of ry
Count _Stat®s Citizenship Country: United States

State of Birth if Country of Birth is USA: _California

Social Security Number *;_&10= b|=4fl0 Race: _Taywanes€

Hair Color:_BlaK__ Eye Color:_Bro-n____Height:_ 57

Alien Registration # (if applicable):__[V/A
194 Arrival/Departure Form Number (11 Digits) __[V/A
Non-Immigrant Visa # (if applicable): V/h

$¥a3” Pagsport Number *:

Passport Country:__ \Unitad __A k3 70702

* Individuals _applying for a SIDA must include their SSN, or TSA will not process the application or conduct
the STA. For individuals applying for AOA Arca mcdia, providing thc SSN is voluntary, but failurc to provide
it may prevent completion of the STA.

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 ABILENE
REGIONAL AIRPORT
CITY OF ABILENE TEXAS

For Individuals who are U.S. citizens born abroad or naturalized U.S. citizens:
U.S. Passport #:
Certification of Naturalization #:
Certification of Birth Abroad, Form DS-1350 #:

Employer: Shi41 S3ctor

Applicant’s Home/Day Phone: _ 44 9-41§5 - 3543

Applicant’s Email Address: __pvadenhuand @ 9mail. @M

Home Address: V5921 Brdlea Dr

City: _ Tusiin State:_( # ZipCode: 12782

Driver's License: State:__ (b Number:_W193% 0 1) Expiration:_\2/17/7027
mnvddlyyyy
In the past ten years, I have been convicted of a crime other than a minor traffic offense:
Yes Y__ No

If you checked Yes, explain:

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 (see Section 1001 of Title 18 of the United States Code).

I authorize the Social Security Administration to release my Social Security Number and full name to the
Transportation Security Administration, Enrollments Services and Vetting Programs, Attention: Vetting
Programs (TSA-10)/Aviation Worker Program, 6595 Springfield Center Drive, Springfield, VA 20598-
6010. '

1 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.

T understand and affirm that once T am issued an airport security badge, T am responsible for its
accountability, reporting my conviction of a criminal offense as listed in 14 CFR Part 1542 and for my
conduct and the conduct of those I escort onto the airport’s restricted access areas. I understand and affirm
that I am responsible for the replacement cost if my badge is lost or stolen and will immediately report my
badge as lost or stolen upon discovering so and that my badge is the property of City of Abilene’s
Department of Aviation and may be suspended or revoked by that department.

W e ze — q/ 5/2024
Applicant’s Signature Date

Print Full Name: Breden Huand

Social Security Number: ‘a1 0= bj-941® of Birth: ___| > /17 / 200k
Date

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//ABILENE A g sofs
REGIONAL AIRPORT
CITY OF ABILENE TEXAS
Privacy Act Notice

Authority: Title 6 of the United States Code (U.S.C.), section 1140, 46 U.S.C. § 70105;49 U.S.C. §§ 106,
114, 5103a, 40103(b)(3), 40113, 44903, 44935-44936, 44939, and 46105; the Implementing Recommendations
of the 9/11 Commission Act of 2007, § 1520 (121 Stat. 444, Public Law 110-53, August 3, 2007); the FAA
Reauthorization Act of 2018, §1934(c), (i) (132 Stat. 3186, Public Law 115-254, Oct 5, 2018), and Executive
Order 9397, as amended.

Purpose: The U.S. Department of Homeland Security (DHS) will use the biographic and biometric
information to conduct a security threat assessment. Your fingerprints and associated information will be
provided to the Federal Bureau of Investigation (FBI). The FBI will compare your fingerprints to other
fingerprints in its Next Generation Identification (NGI) system or its successor systems including civil,
criminal, and latent fingerprint repositories. The FBI may keep your fingerprints and associated information in
NGI after the completion of this application and continue to compare them against other fingerprints submitted
to or kept by NGL DHS will also send your fingerprints for enrollment into the DHS Automated Biometrics
Identification System (IDENT).

DHS will also maintain a national, centralized revocation database. This database will contain the names of
individuals who have had airport-issued identification (ID) media revoked for not complying with aviation
security requirements. Individuals who believe their name is mistakenly entered in the database can ask for the
record to be corrected and have their name removed from the database by following the aircraft or airport
operator’s redress procedures.

Routine Uses: In addition to those disclosures generally permitted under 5 U.S.C. 522a(b) of the Privacy Act,
all or a portion of the records or information contained in this system may be disclosed outside DHS as a
routine use under 5 U.S.C. 522a(b)(3). Routine use includes those uses identified in the TSA system of records
notice DHS/TSA 002, Transportation Security Threat Assessment System. It also includes disclosures to third
parties during a security threat assessment, employment investigation, or adjudication of a waiver or appeal
request as necessary to get information relevant to assessing, investigating, or adjudicating your application.

For as long as your fingerprints and associated information are kept in NGI, your information may be disclosed
with your consent or without your consent as permitted by the Privacy Act of 1974 and all applicable Routine
Uses as published at any time in the Federal Register, including the Routine Uses for the NGI system and the
FBI’s Blanket Routine Uses.

DHS may provide your name and social security number (SSN) to the Social Security Administration (SSA) to
validate that information against SSA records.

Disclosure: Under section 1934(c) of the FAA Reauthorization Act of 2018, TSA must collect your SSN on
applications for Secure Identification Display Area (SIDA) credentials. If you do not provide this information,
TSA will deny your request for a SIDA credential. Although providing your SSN is voluntary for other
aviation credentials, if you do not provide it, DHS may be unable to complete your security threat assessment.

Subject to Search/Screening Notice

Each Badge Holder is subject to search of their person, vehicle, and accessible property while inside the AOA,
Sterile, and Secured Area. Any employee holding a credential granting access to a Security Identification
Display Area (SIDA) may be screened at any time while gaining access to, working in, or leaving a SIDA.

Blp e 9 /52024
Applicant’s Signature Date

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