Form 3078 Application for Identification Card

DEPARTMENT OF HOMELAND SECURITY

U.S. Customs and Border Protection

APPLICATION FOR IDENTIFICATION CARD
19 U.S.C. 66, 1551, 1555, 1565, 1624, 1641;
19 CFR 112.42, 118, 122.182, 146.6

OMB No.1651-0008
Exp. 10-31-2012

2. DATE OF THIS APPLICATION

1. TYPE OF ACTIVITY REQUIRING IDENTIFICATION CARD
Cartman/
Lighterman

Broker's
Employee

CBP
Security Area
Identification

Warehouse Officer
or Employee

Container Station
Employee

3. NAME (Last, First, & Middle)

Foreign
Trade Zone
Employee

CES
Employee

4. SOCIAL SECURITY NUMBER
6. DATE OF BIRTH

5. LIST ANY OTHER NAMES YOU HAVE EVER BEEN KNOWN BY (Nicknames, aliases, etc.)
7. HOME ADDRESS (Number, Street, City, State, and ZIP Code)

8. NAME AND ADDRESS OF PRESENT EMPLOYER

9. HOME PHONE NUMBER

10. BUSINESS PHONE NUMBER

11. PLACE OF BIRTH (City, County, State, and Country)

12. HEIGHT

13. WEIGHT

14. COLOR HAIR 15. COLOR EYES

16. VISIBLE SCARS OR MARKS
17. U.S. COAST GUARD PORT SECURITY CARD NUMBER

18. U.S. MERCHANT MARINE CARD NUMBER

19. HAVE YOU EVER APPLIED FOR CARD IN ITEM 17 OR ITEM 20. HAS APPLICATION FOR EITHER CARD IN ITEM 17 OR 18 BEEN
18?
DENIED?
YES

(Skip Items 20 and 21)

NO

YES

(If Yes, explain in Item 21)

NO

(Skip Item 21)

21. EXPLANATION OF APPLICATION DENIAL
22. LIST ALL RESIDENCES DURING THE LAST 5 YEARS (List in reverse order, beginning with the present address)
DATES
From

Number and Street

To

City

State

PRESENT

23. HAVE YOU EVER SERVED IN THE ARMED SERVICES OF THE U.S.?
YES

NO

24. BRANCH OF SERVICE

(Skip Items 24-28)

25. DATES OF SERVICE

27. TYPE OF DISCHARGE

26. SERIAL NUMBER

28. IF DISCHARGE WAS OTHER THAN HONORABLE, EXPLAIN IN FULL DETAIL

29. HAVE YOU EVER APPLIED FOR AN IDENTIFICATION CARD WITH
U.S. CUSTOMS AND BORDER PROTECTION?

YES

(If Yes, explain details)

NO

CBP Form 3078 (04/08)

30. PREVIOUS EMPLOYMENT -- LIST IN CHRONOLOGICAL ORDER, GIVING EARLIEST EMPLOYMENT FIRST (Last 10 Years)
DATES
From

To

EMPLOYER NAME AND ADDRESS

OCCUPATION

31. HAVE YOU EVER BEEN CONVICTED OF ANY CRIME OR OFFENSE (Other than traffic violations, you
may exclude any items which occurred before your 16th birthday) IN THIS COUNTRY OR ELSEWHERE?

YES (If YES, explain
in Item 32.)

NO

32. EXPLANATION OF ALL CONVICTIONS (Federal, State, Military, or Foreign)

Date

Place

Charge

33. DO YOU NOW USE OR HAVE YOU EVER USED NARCOTIC DRUGS?

35.
CERTIFICATION

I certify that all of the statements made in this Application are
true, complete, and correct to the best of my knowledge and
belief, and are made in good faith.

Court

YES (If YES, explain
below.)

SIGNATURE

X

Final Disposition

NO 34. ATTACH PHOTOGRAPH HERE

DATE

Paperwork Reduction Act Notice: The Paperwork Reduction Act says we must tell you why we are collecting this information, how we will use it, and whether
you have to give it to us. We ask for this information to carry out U.S. Customs and Border Protection laws of the United States. This form is used by
licensed cartmen or lightermen or their employees as an application to apply for a CBP identification card and is required to obtain or retain a benefit. The
estimated average burden associated with this collection of information is 17 minutes per respondent or recordkeeper depending on individual circumstances.
The valid OMB Control Number for this Information Collection is 1651-0008.
Pursuant to the requirements of Public law 93-579 (Privacy Act of 1974), notice is hereby given that the authority to collect information on CBP Form 3078 is
5 U.S.C. 301, Reorganization Plan No. 1 of 1950; 19 U.S.C. 1551, 1565, 1624, 1641; 19 CFR 112.42. The principal purpose for collecting the information is
to enable CBP to conduct a background investigation and thereby determine whether the applicant meets the criteria required for the issuance of an
identification card. The information collected and contained in the applicant's file may be provided to those employees of CBP who have a need for the
records in the performance of their duties. The information may also be used, when deemed appropriate, in a proceeding to revoke or suspend the
identification card. Disclosure of all information requested on CBP Form 3078 is voluntary; however, failure to disclose some or all of this information may
result in CBP's inability to conduct the required background investigation.

CBP Form 3078 (04/08)