Security Threat Assessment for Individuals Applying for a Hazardous Materials Endorsement for a Commercial Driver's License

HTAP Application

INSTRUCTIONS: Applicants are encouraged to take their time and review all information included on this application for the Hazardous Materials Endorsement Threat Assessment Program (HTAP). Prior to applying, you should confirm with your State licensing entity that you meet the eligibility requirements to hold an Hazardous Materials Endorsement (HME) on your commercial driver’s license. You should also confirm your eligibility based on the TSA requirements by reviewing Section VII “TSA Eligibility Requirements” on page 3 of this application. You are required to complete the information and provide the documentation requested on this application in order to undergo a security threat assessment. Completed forms (including an applicant’s signature) must be submitted in person at the beginning of the application process. If you are initially disqualified, you may be eligible for an HME and should apply for an appeal or a waiver, which gives you the opportunity to provide additional information and documentation to support your eligibility.  You must wait for a Preliminary Determination of Ineligibility (PDI) letter before applying for an appeal or a waiver.  All fields are required unless otherwise noted. [Note: if you are currently under indictment or have open criminal charges, it is recommended that you wait to apply until the matter is resolved.]

SECTION I -- PERSONAL INFORMATION PERSONAL INFORMATION

NAME (Last, First, Middle, Suffix)      

SOCIAL SECURITY NUMBER (Optional)      

PREVIOUS NAMES USED (Last, First, Middle, Suffix)      

COMMERCIAL DRIVER LICENSE (CDL) NUMBER      

STATE THAT ISSUED CDL      

HME TYPE (H or X)      

TYPE OF APPLICATION HME Renewal HME Transfer New

IF TRANSFERRING HME, LIST PRIOR CDL NUMBER (If known) AND STATE OF ISSUANCE CDL Number:      State:     

SEX Male Female

DOB (mm/dd/yyyy)       /      /     

HEIGHT       FT.       IN.

WEIGHT       LBS.

HAIR COLOR      

EYE COLOR      

SECTION II -- ADDRESSES

CURRENT RESIDENTIAL ADDRESS      

CITY, STATE, ZIP

CURRENT MAILING ADDRESS (If different than residential address)

CITY, STATE, ZIP

HOME PHONE (Include area code)      

WORK PHONE (Include area code)      

CELL PHONE (Include area code)      

EMAIL ADDRESS      

PREVIOUS RESIDENTIAL ADDRESS      

CITY, STATE, ZIP      

SECTION III -- CITIZENSHIP

Are you a U.S. citizen?

Yes No

COUNTRY OF CITIZENSHIP      

NATURALIZATION DATE (If applicable)      

STATE DEPARTMENT FORM FS-240, FS-545, OR DS-1350 NUMBER (If born abroad to U.S. citizens)      

U.S. PASSPORT NUMBER (If applicable) AND EXPIRATION DATE      

LEGAL STATUS DOCUMENT AND NUMBER (Ref. Page 2, Sec. VI) AND EXPIRATION DATE (If applicable)      

ALIEN REGISTRATION NUMBER (If applicable)      

CITY OF BIRTH      

STATE OF BIRTH (Not required if born outside U.S.)      

COUNTRY OF BIRTH      

SECTION IV -- EMPLOYMENT HISTORY

CURRENT EMPLOYER NAME (If currently in military, put military employment information here)      

CURRENT EMPLOYER PHONE (Include area code)      

CURRENT EMPLOYER ADDRESS      

CITY, STATE, ZIP

1. Have you undergone or are you undergoing a DHS (including TSA) security threat assessment?

Yes No

If yes: Name of program (e.g., Aviation Worker, Certified Cargo Screening, Indirect Air Carrier, TWIC, FAST, MMD, etc.):      

2. Have you had or do you have a DHS/TSA credential (e.g., Aviation Worker, Certified Cargo Screening, Indirect Air Carrier, TWIC, FAST, MMD, etc.)?

Yes No

If yes: Type of credential

     

Credential reference number:      

SECTION V -- CERTIFICATIONS/SIGNATURE

Please refer to Section VII of this form, “Eligibility Requirements.” Answering “Yes” to any questions below does not mean automatic disqualification. Applicants convicted of criminal disqualifiers may be eligible to apply for and be granted a waiver and obtain an HME.

1. Have you been convicted, or found not guilty by reason of insanity, of any disqualifying felony listed in Section 1, Part A, in any jurisdiction, military or civilian, in the last 7 years before the date of this application?

Yes No

2. Have you been released from incarceration in any jurisdiction, military or civilian, for committing any disqualifying felony listed in Section 1, Part A, in during the 5 years before the date of this application?

Yes No

3. Have you been convicted, or found not guilty by reason of insanity, of any disqualifying felony listed in Section 1, Part B, in any jurisdiction, military or civilian?

Yes No

4. Are you wanted or under indictment for any disqualifying crime listed in Section 1, Parts A or B?

Yes No

5. Have you ever been found by a court or other lawful authority as lacking mental capacity or involuntarily committed to a mental institution?

Yes No

I have disclosed any and all information with this application related to disqualifying crimes committed and as required by Federal regulation 49 CFR 1572.5(b), I understand my continuing obligation to disclose to TSA within 24 hours if I am convicted or found not guilty by reason of insanity of any disqualifying crime, or adjudicated as a mental defective or committed to a mental institution, while I have a hazardous materials endorsement for a CDL.

The 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 a hazardous materials endorsement.

Applicant Signature:            Date:      

SECTION VI -- LEGAL STATUS DOCUMENTS

If you possess any of the following documents or cards, please identify it within the “Citizenship” section on page 1 of this form, as well as list the number assigned to your document/card. Please note that a combination of these documents may be required.

Lawful Permanent Residents (LPR) Documents

U.S. Citizenship Documents Continued

Unexpired Foreign Passport AND immigrant visa with I-551 annotation of “Upon Endorsement Serves as Temporary I-551 Evidencing Permanent Residence of 1 Year” Unexpired Permanent Resident Card (I-551) Unexpired Re-entry Permit (I-327)

Consular Report of Birth Abroad (FS-240) Certification of Report of Birth Abroad (DS-1350 or FS-545) Department of Transportation (DOT) medical card Expired U.S. Passport (within 12 months of expiration) Native American tribal document (with photo) Original or certified copy of birth certificate issued by a State, county, municipal authority, or outlying possession of the United States bearing an official seal U.S. Certificate of Citizenship (N-560 or 561) U.S. Citizen Identification Card (I-179 or I-197) U.S. Certificate of Naturalization (N-550 or 570) U.S. military ID card or U.S. retired military ID U.S. military dependent’s card U.S. military discharge papers (DD-214) U.S. civil marriage certificate U.S. social security card Voter’s registration card

U.S. Citizenship Documents

Unexpired Department of Homeland Security (DHS)/Transportation Security Administration (TSA) Transportation Worker Identification Credential (TWIC) Unexpired driver’s license issued by a State or outlying possession of the United States Unexpired Enhanced Tribal Card (ETC) Unexpired Free and Secure Trade (FAST) Card Unexpired ID card issued by a State or outlying possession of the United States. Must include a State or State agency seal or logo Unexpired Merchant Mariner Credential (MMC) Unexpired Merchant Mariner Document (MMD) Unexpired Merchant Mariner License (MML) bearing an official raised seal, or a certified copy Unexpired NEXUS Card Unexpired U.S. Passport (book or card) Unexpired Secure Electronic Network for Travelers Rapid Inspection (SENTRI) Card Unexpired U.S. Enhanced Driver’s License (EDL)

SECTION VII – TSA ELIGIBILITY REQUIREMENTS

Section 1: List of Disqualifying Criminal Offenses for an HME (49 CFR 1572.103)

Part A: Interim Disqualifying Offenses

A driver will be disqualified from holding an HME on a CDL if he or she was convicted or found not guilty by reason of insanity within the previous seven years or was released from prison in the last five years for any of the following felonies:

1. Unlawful possession, use, sale, manufacture, purchase, distribution, receipt, transfer, shipping, transporting, delivery, import, export of, or dealing in a firearm or other weapon

2. Extortion

3. Dishonesty, fraud, or misrepresentation, including identity fraud and money laundering (except welfare fraud and passing bad checks)

4. Bribery

5. Smuggling

6. Immigration violations

7. Distribution, possession w/ intent to distribute, or importation of a controlled substance

8. Arson

9. Kidnapping or hostage taking

10. Rape or aggravated sexual abuse

11. Assault with intent to kill

12. Robbery

13. Fraudulent entry into a seaport

14. Lesser violations of the RICO (Racketeer Influenced and Corrupt Organizations) Act

15. Conspiracy or attempt to commit crimes in this section

Part B: Permanently Disqualifying Criminal Offenses

A driver will be disqualified from holding an HME on a CDL if he or she was convicted or found not guilty by reason of insanity for any of the following felonies:

1. Espionage or conspiracy to commit espionage

2. Sedition or conspiracy to commit sedition

3. Treason or conspiracy to commit treason

4. A federal crime of terrorism

5. A crime involving a TSI (transportation security incident). Note: A transportation security incident is a security incident resulting in a significant loss of life, environmental damage, transportation system disruption, or economic disruption in a particular area.  The term “economic disruption” does not include a work stoppage or other employee-related action not related to terrorism and resulting from an employer-employee dispute.

6. Improper transportation of a hazardous material under 49 U.S.C. 5124 or a comparable state law

7. Unlawful possession, use, sale, distribution, manufacture, purchase…or dealing in an explosive or explosive device

8. Murder

9. Threat or maliciously conveying false information knowing the same to be false, concerning the deliverance, placement, or detonation of an explosive or other lethal device in or against a place of public use, a state or government facility, a public transportations system, or an infrastructure facility

10. Certain RICO (Racketeer influenced and Corrupt Organizations) Act violations where one of the predicate acts consists of one of the permanently disqualifying crimes

11. Attempt to commit the crimes in items (a)-(d) of this section

12. Conspiracy or attempt to commit the crimes in items (e)-(j) of this section

13. Individuals convicted of the crimes in items (a)-(d) of this section are not eligible to apply for a waiver

Part C: Under Want or Warrant

A driver will be disqualified from holding an HME on a CDL if he or she is wanted or under indictment in any civilian or military jurisdiction for a felony listed under Part A or Part B until the want or warrant is released.

Section 2: Permissible Legal Status to Hold an HME (49 CFR 1572.105)

An individual applying for a security threat assessment for an HME must be a national of the United States or:

1. A lawful permanent resident of the United States;

2. A refugee admitted under 8 U.S.C. 1157;

3. An alien granted asylum under 8 U.S.C. 1158;

4. An alien in valid M–1 nonimmigrant status who is enrolled in the United States Merchant Marine Academy or a comparable State maritime academy. Such individuals may serve as unlicensed mariners on a documented vessel, regardless of their nationality, under 46 U.S.C. 8103;

5. A nonimmigrant alien admitted under the Compact of Free Association between the United States and the Federated States of Micronesia, the United States and the Republic of the Marshall Islands, or the United States and Palau;

6. An alien in lawful nonimmigrant status who has unrestricted authorization to work in the United States, except—

   1. An alien in valid S–5 (informant of criminal organization information) lawful nonimmigrant status;

   2. An alien in valid S–6 (informant of terrorism information) lawful nonimmigrant status;

   3. An alien in valid K–1 (Fianco(e)) lawful nonimmigrant status; or

   4. An alien in valid K–2 (Minor child of Fianco(e)) lawful nonimmigrant status.

7. An alien in the following lawful nonimmigrant status who has restricted authorization to work in the United States—

   1. B1/OCS Business Visitor/Outer Continental Shelf;

   2. C–1/D Crewman Visa;

   3. H–1B Special Occupations;

   4. H–1B1 Free Trade Agreement;

   5. E–1 Treaty Trader;

   6. E-2 Treaty Investor;

   7. E–3 Australian in Specialty Occupation;

   8. L-1A Intracompany Transfer -- Managerial or Executive Positions;

   9. L-1B Intracompany Transfer -- Specialized Knowledge Staff;

   10. O–1 Extraordinary Ability; or

   11. TN North American Free Trade Agreement.

PRIVACY ACT STATEMENT: Authority: The authority for collecting this information is 49 U.S.C. 114, 40113, and 49 U.S.C. 5103a. Principal Purpose(s): This information is needed to verify your identity and to conduct a security threat assessment to evaluate your suitability for a hazardous materials endorsement for a commercial driver’s license. Furnishing this information, including your SSN or alien registration number, is voluntary; however, failure to provide it will prevent the completion of your security threat assessment, without which you cannot be granted a hazardous materials endorsement. Routine Use(s): Routine uses of this information include disclosure to the FBI to retrieve your criminal history record; to TSA contractors or other agents who are providing services relating to the security threat assessments; to appropriate governmental agencies for licensing, law enforcement, or security purposes, or in the interests of national security; and to foreign and international governmental authorities in accordance with law and international agreement. For additional details, see TSA’s system of records notice for DHS/TSA 002, published in the Federal Register at 69 Fed. Reg. 57348 (September 24, 2004). PAPERWORK REDUCTION ACT STATEMENT: Statement of Public Burden:  Public Burden: It is estimated that the time to complete this form is approximately 30 minutes. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The control number for this collection is OMB 1652-0027.

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TSA Form 2214, 02/10 [File: 2200.5.1-b] OMB No. 1652-0027 Expires: 07/31/2011