OMB control number 1652-0040
Expiration Date: 04/30/2024
DEPARTMENT OF HOMELAND SECURITY
Transportation Security Administration
APPLICATION FOR NEW OR RENEWAL SECURITY THREAT ASSESSMENT (STA)
All fie lds are to be comple te d unless otherwis e noted.
SEC T ION I. General Inform ation
Current STA Number (STA Renewals Only):
Current Employer Name:
Current Employer Corporate Address:
City:
State:
Zip:
Employer Phone Number:
IAC Principal
(Refer to Section 1 For Definition):
Yes No
IAC Principal Title (If IAC Principal):
Does Principal Reside In
The United States?
Yes No
Social Security Number (Optional):
Name (First, Middle, Last, Suffix) As it appears on the document presented – See Instructions:
First Middle
Last Suffix
Previous Name Used (First, Middle, Last, Suffix) (If Applicable – See
Instructions):
First Middle
Last Suffix
Previous Name Used (First, Middle, Last, Suffix) (If Applicable – See Instructions):
First Middle
Last
Suffix
Email Address (If Applicable):
Daytime Phone Number:
Gender:
Ma le Female
Place of Birth (City, State, Country):
City:
State: Country:
Country of Citizenship:
Alien Registration Number (If Applicable):
Naturalization Date ( MM/DD/YYYY) (If Applicable):
Applicable):
US Passport Number or Certificate of
Birth Abroad Number (If Applicable):
Current Mailing Address:
Address:
City:
State:
Country:
Zip Code:
Current Residential Address or Same As Mailing Address
Address:
Start Date at this Address
(MM/DD/YYYY):
End Date at this Address:
CURRENT
City:
State:
Country:
Zip Code:
Previous Residential Address (If Applicable, See Instructions):
Address:
Start Date at this Address
(MM/DD/YYYY):
End Date at this Address (MM/DD/YYYY):
City:
State:
Country:
Zip Code:
Previous Residential Address (If Applicable, See Instructions):
Address:
Start Date at this Address
(MM/DD/YYYY):
End Date at this Address (MM/DD/YYYY):
City:
State:
Country:
Zip Code:
Previous editions of this form are obsolete.
TSA Form 419F (11/21) rev [File: 400.18] Page 1 of 6
OMB control number 1652-0040
Expiration Date: 04/30/2024
DEPARTMENT OF HOMELAND SECURITY
Transportation Security Administration
APPLICATION FOR NEW OR RENEWAL SECURITY THREAT ASSESSMENT (STA)
All fie lds are to be comple te d unless otherwise noted.
Previous Residential Address (If Applicable, See Instructions):
Address:
Start Date at this Address
(MM/DD/YYYY):
End Date at this Address (MM/DD/YYYY):
City: State: Country: Zip Code:
Previous Residential Address (If Applicable, See Instructions):
Address:
Start Date at this Address
(MM/DD/YYYY):
End Date at this Address (MM/DD/YYYY):
City: State: Country: Zip Code:
SECTION II. Applicant Acknowledgement
This 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 a knowing and willful false
statement, or an omission of a material fact, on this application can be punished by fine or imprisonment or both (see section 1001 of Title 18 United States Code), and may be grounds for denial of
authorization or in the case of parties regulated under this section, removal of authorization to operate under this chapter, if applicable. I acknowledge that if I do not successfully complete the
Security Threat Assessment (STA), the Transportation Security Administration (TSA) may notify my employer. If TSA or other law enforcement agency becomes aware that I may pose an imminent
threat to an operator or facility, TSA may provide limited information necessary to reduce the risk of injury or damage to the operator or facility.
Applicant Signature:
Date (MM/DD/YYYY):
I have authenticated the identity and work authorization of the individual for whom this STA application is being submitted by reviewing a Photo Identification issued by a government authority and
work authorization documents as required under 49 C.F.R § 1540.203(b). I have verified that the individual's written application contains the Privacy Act Notice required under 49 C.F.R.§
1540.203(c)(11), and I acknowledge that I am required to retain the individual's signed STA application, all documents to prove identity and work authorization, and any communications with TSA
regarding the individual's application (eitherin electronic or hardcopy format) for 180 days following at the end of the individual's service as required under 49 C.F.R. § 1540.203(d).
SECTION III. Employer Acknowledgement
Employer Signature:
Date (MM/DD/YYYY):
Previous editions of this form are obsolete.
TSA Form 419F (11/21) rev [File: 400.18] Page 2 of 6
OMB control number 1652-0040
Expiration Date: 04/30/2024
DEPARTMENT OF HOMELAND SECURITY
Transportation Security Administration
APPLICATION FOR NEW OR RENEWAL SECURITY THREAT ASSESSMENT (STA)
All fie lds are to be comple te d unless otherwise noted.
Section 1. Who Needs to Complete a Security Threat Assessment:
The follow ing sections are contained in the Code of Federal Regulations.
§1548.15 Access to cargo: Security Threat As s essments for individuals having unescorted access to cargo.
a. Before an indirect air carrier authorizes and before an individual perf orms a function described in paragraph (b)
of this section:
1. Each individual must successfully complete a security threat assessment or comparable security threat
assessment described in part 1540 subpart C of this chapter; and
2. Each indirect air carrier must complete the requirements in part 1540 subpart C.
b. The security threat assessment required in paragraph (a) of this section applies to the follow ing:
1. Each individual w ho has unescorted access to cargo and access to inf ormation that such cargo w ill be
transported on a passenger aircraft; or w ho perf orms certain functions related to the transportation,
dispatch or security of cargo for transport on a passenger aircraft or all-cargo as specified in the direct
air carrier's security program; from the time:
i. Cargo to be transported on all cargo aircraft operator w ith a full all-cargo program under §
1544.01 (a) or by a foreign air carrier under § 1546.10(a) or (b) of this chapter, is accepted by
the indirect air carrier, until the indirect air carrier transfers the cargo to an aircraft operator or
foreign air carrier.
ii. Cargo to be transported on a passenger aircraft operated by an aircraf t operator w ith a full program under § 1544.101(a) or by a
foreign air carrier under § 1546.101(a) or (b) of this chapter, is accepted by the indirect air carrier, until the indirect air carrier transfers
the cargo to an aircraft operator or foreign air carrier.
2. Each individual the indirect air carrier authorizes to screen cargo or to supervise the screening of
cargo under § 1548.21.
§1548.16 Security Threat Assessment for each proprietor, general partner, officer, director, and certain owners of the entity.
a. Before an indirect air carrier permits a proprietor, general partner, officer, director, or ow ner of the entity to
perform those functions:
1. The proprietor, general partner, officer, director, or ow ner, of the entity must successfully complete a
security threat assessment or comparable security threat assessment described in part 1540 subpart C
of this chapter; and
2. Each indirect air carrier must complete the requirements in 49 CFR part 1540, subpart C.
b. For purpose of this section, ow ner means:
1. A person w ho directly or indirectly ow n, controls, or has pow er to vote 25 percent or more of any class
of voting securities or other voting interests of an IAC or applicant to be an IAC; or
2. A person w ho directly or indirectly controls in any manner the election of a majority of the directors (or
individuals exercising similar f unctions) of an IAC, or applicant to be an IAC.
c. For purposes of this definition of ow ner:
1. Members of the same f amily must be considered to be one person:
i. Same family means parents, spouses, children, siblings, uncles, aunts, grandparents,
grandchildren, first cousins, stepchildren, stepsiblings, and parents-in-law , and spouses of any
of the foregoing.
ii. Each member of the same family, w ho has an ow nership interest in an IAC, or an applicant to
be an IAC, must be identif ied if the family is an ow ner as a result of aggravating the ow nership
of interests of the same family, any voting interest of any family member must be taken into
account.
iii. In determining the ow nership of interests of the same f amily, any voting interest of any family
member must be taken into account.
2. Voting securities or other voting interest means securities or other interests that entitle the holder to
vote f or or select directors (or individuals exercising similar functions).
d. Each indirect air carrier, or applicant to be an indirect air carrier, must ensure that each proprietor, general
partner, off icer, director, and ow ner, of the entity has successfully completed a Security Threat Assessment
under part 1540, subpart C, of this chapter not later than a date to be specified by TSA in a future role in the
Federal Register.
Previous editions of this form are obsolete.
TSA Form 419F (11/21) rev [File: 400.18] Page 3 of 6
OMB control number 1652-0040
Expiration Date: 04/30/2024
DEPARTMENT OF HOMELAND SECURITY
Transportation Security Administration
APPLICATION FOR NEW OR RENEWAL SECURITY THREAT ASSESSMENT (STA)
All fie lds are to be comple te d unless otherwise noted.
§1549.111 Security Threat Assessment for personnel of certified cargo screening facilities.
a. Scope. This section applies to the follow ing:
1. Each individual the certif ied cargo screening facility authorizes to perform cargo screening or supervise cargo
screening.
2. Each individual the certif ied cargo screening f acility authorizes to have unescorted access to cargo at any
time from the time it is screening until the time it is tendered to another certified cargo screening facility, an
indirect air carrier under 49 CFR part 1548 for transport on a passenger aircraf t, an aircraft operator under
part 1544, or a foreign air carrier under part 1546.
3. The senior manager or representative of its facility in control of the operations.
4. The security coordinators and their alternates.
b. The security threat assessment required in paragraph (a) of this section applies to the follow ing:
1. Each individual w ho has unescorted access to cargo and access to inf ormation that such cargo w ill be
transported on a passenger aircraf t; or w ho has unescorted access to cargo that has been screened for
dispatch, or security of cargo f or transport on a passenger aircraft or all-cargo aircraft, as specif ied in the
aircraft operator's security program - f rom the time:
i. The cargo reaches a location w here an aircraft operator w ith a full all-cargo program consolidates or
inspects it pursuant to security program requirements until the cargo enters an airport Security
Identification Display Area or is transferred to another TSA regulated aircraf t operator, foreign air
carrier, or indirect air carrier; or
ii. An aircraft operator w ith a full program accepts the cargo until the cargo:
o Enters an airport Security Identification Display Area;
o Is removed from the destination airport; or
o Is transferred to another TSA regulated aircraft operator, f oreign air carrier, or indirect air
carrier.
2. Each individual the aircraft operator authorizes to screen cargo or to supervise the screening of cargo under §
1544.205.
§1544.228 Access to cargo and cargo screening: Security Threat Assessments for cargo personnel in the United States. This
section applies in the United States to each aircraf t operator operating under a f ull program under § 1544.101(a) or a full all-cargo
program under § 1544.101(h).
a. Before an aircraft operator authorizes and before an individual perf orms a functions described in paragraph (b) of this
section:
1. Each individual must successfully complete a security threat assessment or comparable security threat
assessment described in part 1540 subpart C of this chapter; and
2. Each aircraft operator must complete the requirements in part 1540 subpart C.
b. The security threat assessment required in paragraph (a) of this section applies to the follow ing:
1. Each individual w ho has unescorted access to cargo and access to information that such cargo w ill
be transported on a passenger aircraft; or w ho has unescorted access to cargo that has been
screened f or security of cargo for transport on a passenger aircraft or all-cargo aircraft, as specified
in the aircraf t operator's security program; from the time:
i. The cargo reaches a location w here an aircraft operator w ith a f ull all-cargo program
consolidates or inspects it pursuant to security program requirements until the cargo enter
an airport Security Identif ication Display Area or is transferred to another TSA regulated
aircraft operator, foreign air carrier, or indirect air carrier; or
ii. An aircraft operator w ith a full program accepts the cargo until the cargo:
A. Enters an airport Security Identif ication Display Area;
B. Is removed from the destination airport; or
C. Is transferred to another TSA regulated aircraft operator, foreign air carrier, or
indirect air carrier.
2. Each individual the aircraft operator authorizes to screen cargo or to supervise the screening of
cargo under §1544.205.
§1546.213 Access to cargo: Security Threat Assessments for cargo personnel in the Unite d States. This section applies in the
United States to each foreign air carrier operating under § 1546.101 (a), (b), or (e)
a. Before a foreign air carrier authorizes and before an individual performs a functions described in paragraph
(b) of this section:
1. Each individual must successfully complete a security threat assessment or comparable security
threat assessment described in part 1540 subpart C of this chapter; and
Previous editions of this form are obsolete.
TSA Form 419F (11/21) rev [File: 400.18] Page 4 of 6
OMB control number 1652-0040
Expiration Date: 04/30/2024
DEPARTMENT OF HOMELAND SECURITY
Transportation Security Administration
APPLICATION FOR NEW OR RENEWAL SECURITY THREAT ASSESSMENT (STA)
All fie lds are to be comple te d unless otherwise noted.
2. Each aircraft operator must complete the requirements in part 1540 part C
b. The security threat assessment required in paragraph (a) of this section applies to the follow ing:
1. Each individual w ho has unescorted access to cargo and access to cargo that has been screened for
transport on a passenger aircraft or all-cargo aircraft, as specif ied in the foreign aircraf t operator's or
foreign air carrier's security program-from the time:
i. The cargo reaches a location w here a foreign air carrier under §1546.101 (e) consolidates or
inspects it pursuant to security program requirements, until the cargo enters an airport
Security Identification Display Area or is transferred to another TSA regulated aircraft
operator, foreign air carrier, or indirect air carrier; or
ii. A foreign air carrier under §§ 1546.101 (a) or (b) accepts the cargo, until the cargo:
o Enters an airport Security Identif ication Display Area;
o Is removed from the destination airport; or
o Is transferred to another TSA regulated aircraft operator, f oreign air carrier, or
indirect air carrier.
2. Each individual the f oreign air carrier authorizes to screening cargo or to supervise the screening of
cargo under § 1546.205.
Section 2. Instructions for Completing the Application:
Country of Citizenship: If the applicant is a U.S. citizen born abroad please provide the 10-digit document number from the applicant's
Certif icate of Birth Abroad, Form DS-1350. If the applicant has been naturalized as a US Citizen, please provide your US passport
number or Date of Naturalization and Naturalization Certif icate Number. Be sure to designate that you are a US citizen if you have been
naturalized.
Alien Registration Number: Please provide your Alien Registration Number if you are not a US citizen. Please do not enter an "A"
before the Alien Registration Number.
Residential/Physical Address Information:Please provide the last 5 years of residential address information (no PO Boxes). use the
back of the form or attach an additional sheet if you need to submit more than 5 residential addresses.
Social Security Num ber: Social Security Number is optional but failure to provide it may result in a delay or prevent completion of
Security Threat Assessment.
Section 3. IAC Principal Definition:
Anyone w ho is a proprietor, general partner, officer, director, or ow ner of the entity. Ow ner means a person w ho directly or indirectly
ow n, controls, or has pow er to vote 25 percent or more of any class of voting securities or other voting interests of an IAC or applicant
to be an IAC; or a person w ho directly or indirectly controls in any manner the election of a majority of the directors (or individuals
exercising similar functions) of an IAC, or applicant to be an IAC.
Examples of Previous and Other Names:
Example A: Name: Melissa Anna Brow n Name on the Government picture ID and Work authorization are the same. Melissa
Anna Brown must be listed as the Applicants Name in the STA Application Name field.
Example B: Name: Melissa Anna Brown Government picture ID names Melissa Anna Brow n but the Work authorization names
Melissa A. Brown. Melissa Anna Brown must be listed as the Applicants Name in the STA Application Name field AND Melissa
A. Brow n must be listed on the STA Application Previous and Other Names field.
Example C: Name: Melissa A. Brow n Government picture ID names Melissa A. Brow n but the Work authorization names
Melissa Anna Brow n. Melissa Anna Brown must be listed as the Applicants Name in the STA Application Name field AND
Melissa A. Brow n must be listed on the STA Application and Other Names field.
NOT E: If the Applicant has a middle name that does not appear on the ID or w ork authorization, or if the Applicant is know n by more
than one name, each name must be included in the Previous and Other Names data field. If the Applicant uses an initial as part of
his/her name, the initial must be spelled out in the Previous and Other Names data field w ith the rest of the Applicants full name.
Previous and Other Names include Alias, Nicknames, Maiden Names.
Section 4. Privacy Act and Paperwork Reduction Act Notices:
Privacy Act Statement: Authority: The authority for collecting this information is 49 U.S.C. §§ 114 and 44901. Principal Purpose: T his
information is needed to verify your identity and to conduct a Security T hreat Assessment to evaluate your suitability for completing the functions
required by this position. Routine Use s: Routine uses of this information include disclosure to TSA contractors or other agents who are providing
services relating to the Security T hreat Assessments; to appropriate governmental agencies for law enforcement or security purposes, or in the
Previous editions of this form are obsolete.
TSA Form 419F (11/21) rev [File: 400.18] Page 5 of 6
OMB control number 1652-0040
Expiration Date: 04/30/2024
DEPARTMENT OF HOMELAND SECURITY
Transportation Security Administration
APPLICATION FOR NEW OR RENEWAL SECURITY THREAT ASSESSMENT (STA)
All fie lds are to be comple te d unless otherwise noted.
interests of national security; to foreign and international governmental authorities in accordance with law and international agreement; or for this
routine uses identified in TSA system of records, DHS/TSA 002 Transportation Security Threat Assessment System. Disclosure: Failure to furnish
your SSN may result in delays in processing your application, but will not prevent completion of your Security T hreat Assessment. Furnishing the
other information is mandatory and failure to provide it may result in you not being granted authorization to have unescorted access to air cargo.
Paperwork Reduction Act Burden Statement: T SA is collecting this mandatory collection of information to qualify ent it ies pursuant to 49 CFR §§
1548.15, 1548.16, 1549.111, 1544.228, and 1546.213. The public burden for this collection of information is estimated to be approximately 15
minutes. An agency may not conduct or sponsor, and persons are not required to, a collection of information unless it displays a valid OMB cont rol
number. The control number assigned to this collection is OMB number 1652-0040, which expires04/30/2024. Send comments regarding t his burden
estimate or any other aspect of this collection of information including suggestions for reducing t h is burden t o T SA P RA Officer, T SA-11, 6595
Springfield Center Drive, Springfield, VA 20598-6011. ATTN: PRA 1654-0040.
Previous editions of this form are obsolete.
TSA Form 419F (11/21) rev [File: 400.18] Page 6 of 6