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

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

HME_workstation_comp2

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

OMB: 1652-0027

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Universal
EnrollmentNashville
Services TN (8023)
Service Location:
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Appointments

*Date of Birth

Last Name

First Name

MI

Program

Service

Appointment

Smith

John

S

HME

Enroll

9:00am

Clever

Joe

D

HME

Enroll

9:15am

Search Method

Grey

Steven

R

TWIC

Activate Card

9:30am

Phone

Thompson

Joanne

C

TWIC

Enroll

10:15am

Country Code

Clark

James

F

Pre

Enroll

10:30am

Gregory

George

S

Pre

Enroll

10:30am

Williams

Amy

A

TWIC

Enroll

10:45am

Hartwell

Paul

R

TWIC

Reset Card PIN

11:00am

Wells

Steve

H

TWIC

Enroll

11:30am

Anderson

Robert

J

HME

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12:00pm

Cook

John

D

Pre

Enroll

12:15pm

Fellows

Keith

W

TWIC

Reset Card PIN

12:30pm

Simmons

Chris

N

Pre

Enroll

12:45pm

Subject

Hoover

Richard

K

TWIC

Enroll

1:00pm

Service Outage

Lester

David

D

TWIC

Activate Card

1:30pm

Training Module Due

Freeman

Steven

S

TWIC

Enroll

1:45pm

United States (+1)
Phone

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Message Center
Date

! 07/16/13
07/10/13

Print Appointments

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Admin
1

EN 7/16/2013 @ 8:56 AM

Universal
EnrollmentNashville
Services TN (8023)
Service Location:
Search

Appointments

*Date of Birth

12/30/1972
December 30, 1972

Search Method

Last Name

First Name

MI

Program

Service

Appointment

Smith

John

S

HME

Enroll

9:00am

Smith

John

S

Walk-in

New

Walk-in

Phone
Country Code

United States (+1)
Phone

615-123-4567

Search

Clear

Message Center
Date

! 07/16/13
07/10/13

Subject

Service Outage
Training Module Due

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Admin
1

EN 7/16/2013 @ 7:56 AM

Universal
EnrollmentNashville
Services TN (8023)
Service Location:
Enter Customer Information
Essential

Contact

*First Name

*Preferred Language

John

English

*Middle Name

*Method of Contact 1
Country Code

Steven

United States (+1)
*Last Name

Smith
*Gender

*Primary Method of Contact

Method of Contact 1

Phone

615-123-4567

Suffix
*Method of Contact 2
Method

None

Male
*Date of Birth

12/30/1972

Email Receipt to

jsmith@comcast.net

December 30, 1972

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1

EN 7/16/2013 @ 8:56 AM

Universal
Services
UniversalEnrollment
Enrollment
Services
Select Program

Select Customer Service
Enroll
Transfer

HazMat

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1

EN 7/16/2013 @ 8:56 AM

Universal
Enrollment Services
Prepare Service
Determine Enrollment History
* Commercial Driver License Number

00123456

South Dakota

* Prior CDL information
* Commercial Driver License Number

65465412

Back

*State of Issuance

*State/Province of Issuance

Tennessee

Service

Identity

Fee

Payment

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1

EN 7/16/2013 @ 8:56 AM

Universal
Enrollment Services
Prove Identity
Determine Citizenship
*Country of Birth

United States
*City of Birth

*State/Province of Birth

Nashville

Tennessee

*Country of Citizenship

United States

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Identity

Fee

Payment

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1

EN 7/16/2013 @ 8:56 AM

Prove Identity
Determine Documents
Documents

Additional Documents

Transportation Worker Identification Credential (TWIC)
Driver’s license issued by a State or outlying possession of the U.S.
Enhanced Tribal Card (ETC)
Free And Secure Trade (FAST) Card
ID card issued by a State or outlying possession of the U.S.
U.S. Passport Book or Passport Card
Merchant Mariner Credential (MMC)
Merchant Mariner Document (MMD)
Merchant Mariner License (MML) with official seal or certified copy
NEXUS Card
U.S. Passport (book or card)
Secure Electronic Network for Travelers Rapid Inspection (SENTRI)
United States Enhanced Driver’s License (EDL)
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,

Back

Service

Identity

Fee

Payment

-AND-

Required Identity Documents:
U.S. Passport Book or Passport Card

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EN 7/16/2013 @ 8:56 AM

Universal
Enrollment Services
Prove Identity
Accepted
*Document Number:

100003106
*Issuance Date:

*Expiration Date:

11/25/2005

11/24/2015

November 25, 2005

November 24, 2015

Comment:

Scan

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Identity

Fee

Payment

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1

EN 7/16/2013 @ 8:56 AM

Universal
Enrollment
Services
Determine
Fee
Calculate Fee
$86.50 - Full Fee (HME expires approximately May 2014)

$86.50

Authorization Code

Apply

Fee: $86.50

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Identity

Fee

Payment

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1

EN 7/16/2013 @ 8:56 AM

Universal
Enrollment
Services
Collect Payment
y
Choose Payment Method

Credit Card

Check

Amount Due $86.50

Money Order

Swipe Card
We Accept

* Name on Card

John Smith
* Credit Card Number

4444657591231475
* Expiration Date

08

/

14

* CSC

152

Charge
ge

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Identity

Fee

Payment

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1

EN 7/16/2013 @ 8:56 AM

Universal
Enrollment
Services
y
Collect Payment
Choose Payment Method

Credit Card

Check

Amount Due $86.50

Money Order

Swipe Card
We Accept

Credit Card ending in 5012
was successfully charged

$86.50
* Name on Card

John Smith
* Credit Card Number

4444657591231475
* Expiration Date

08

/

14

* CSC

152

Charge

Back

Service

Identity

Fee

Payment

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1

EN 7/16/2013 @ 8:56 AM

Universal
Services
Capture Enrollment
Biographics
Answer Personal Questions
* 1. Have you ever used a maiden/previous name?

Yes

No

* 2. Have you ever used an alias?

Yes

No

* 3. Is your mailing address the same as your residential address?

Yes

No

* 4. Have you lived at your current residential address for more than five (5) years?

Yes

No

Key Pad Functions

1 = Yes

Back

2 = No

7 = Move back to previous question

Service

Identity

Fee

Payment

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Submit
1

EN 7/16/2013 @ 8:56 AM

Universal
Services
Capture Enrollment
Biographics
Enter Personal Information
First Name

Middle Name

Last Name

John

Steven

Smith

Suffix

Date of Birth

Gender

12/30/1972

Male

December 30, 1972

* Maiden/Previous Name
* First Name

* Middle Name

* Last Name

Jimmy

NMN

John

* Alias
* First Name

* Middle Name

* Last Name

Jimmy

Hunter

John

US
Metric
Height
*

6

ft

2

* Weight

in

205

lbs

* Hair Color

* Eye Color

Brown

Multi-color

Social Security Number

Suffix

Social Security Number

*********

Back

Suffix

111-08-5114

Service

Identity

Fee

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1

EN 7/16/2013 @ 8:56 AM

Universal
Services
Capture Enrollment
Biographics
Enter Mailing Address
* Country

United States
* Address Line 1

15 Century Blvd
Address Line 2

Suite 110
* City

* State/Province

* Postal Code

Nashville

Tennessee

37214 - 0129

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EN 9/25/2012 @ 7:56 AM

Universal
Services
Capture Enrollment
Biographics
Enter Residential Address
* Country

United States
* Address Line 1

123 Elm Hill Pike
Address Line 2

* City

* State/Province

* Postal Code

Nashville

Tennessee

37214 - 0129

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1

EN 7/16/2013 @ 8:56 AM

Universal
Services
Capture Enrollment
Biographics
Enter Previous Address
* Country

United States
* Address Line 1

125 Main Street
Address Line 2

Suite 110
* City

* State/Province

* Postal Code

Murfreesboro

Tennessee

37129 - 0129

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EN 9/25/2012 @ 7:56 AM

Universal
Services
Capture Enrollment
Biographics
Enter Employment Information
* Employment Status

Occupation or Trade

Currently Employed

Trucker

* Current Employer Name

* Country

ACME Supply Company

Canada

Address Line 1

123 Great White North Road
Address Line 2

* City

* State/Province

Postal Code

Montreal

Quebec

37214 - 0129

Country Code

Phone

Canada (+1)

408-688-7942

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Identity

Fee

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1

EN 7/16/2013 @ 8:56 AM

Universal
Services
Capture Enrollment
Fingerprints
Place Fingers on Device
3
2

4

5

Service

Identity

Fee

Payment

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Fingerprints

Disclosure

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1

EN 7/16/2013 @ 8:56 AM

Universal
Services
Capture Enrollment
Fingerprints
Passed
3
2

4

3

4

5

2
5

Right Fingers

Rescan

Service

Identity

Fee

Payment

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Fingerprints

Disclosure

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1

EN 7/16/2013 @ 8:56 AM

Universal
Services
Capture Enrollment
Fingerprints
Place Thumbs on Device

6

1

Service

Identity

Fee

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1

EN 7/16/2013 @ 8:56 AM

Universal
Services
Capture Enrollment
Fingerprints
Passed

6

1

6

1

Rescan

Service

Identity

Fee

Payment

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1

EN 7/16/2013 @ 8:56 AM

Universal
Services
Capture Enrollment
Fingerprints
Place Fingers on Device
9

8
7

0

Service

Identity

Fee

Payment

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Fingerprints

Disclosure

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1

EN 7/16/2013 @ 8:56 AM

Universal
Services
Capture Enrollment
Fingerprints
Passed
9

8
7

8

9
0

7

Right Fingers

Rescan

Service

Identity

Fee

Payment

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Fingerprints

Disclosure

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1

EN 7/16/2013 @ 8:56 AM

Universal
Capture Enrollment
DisclosureServices
Answer Questions
If you answer ‘Yes’ to question 5, because you are currently under indictment or have open criminal charges, you should consider waiting to apply until these
matters are resolved as enrollment fees are not refunded.

1. Are you a U.S. citizen?

Yes

No

2. Excluding juvenile cases unless convicted as an adult, have you been convicted, pled guilty including “no contest”, or found
not guilty by reason of insanity, of any disqualifying felony listed in 49 CFR 1572.103 (Section VII, Part A), in any jurisdiction,
military or civilian?

Yes

No

3. Excluding juvenile cases unless convicted as an adult, have you been convicted, pled guilty including “no contest”, or found
not guilty by reason of insanity, of any disqualifying felony listed in 49 CFR 1572.103 (Section VII, Part B), in any jurisdiction,
military or civilian, during the 7 years before the date of this application?

Yes

No

4. Have you been released from incarceration in any jurisdiction, military or civilian, for committing any disqualifying felony listed
in 49 CFR 1572.103 (Section VII, Part B), during the 5 years before the date of this application?

Yes

No

5. Are you wanted or under indictment for any disqualifying crime listed in listed in 49 CFR 1572.103 (Section VII,
Parts A and B)?

Yes

No

6. 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

Key Pad Functions

1 = Yes

2 = No

7 = Move back to previous question

Service

Identity

Fee

Payment

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1

EN 7/16/2013 @ 8:56 AM

Universal
Capture Enrollment
DisclosureServices
Accepted
I understand my continuing obligation to notify 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 am enrolled in the Hazardous Materials Endorsement Threat Assessment Program.
The information I 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 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 my application for the Hazardous Materials Endorsement Threat Assessment Program by TSA.

John S. Smith

Comment:

Translator used to interpret disclosure
Comment:

Scan

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1

EN 7/16/2013 @ 8:56 AM

Universal
Enrollment
Customer
Survey Services
Answer Survey Questions
Each question is viewable only by you and will allow only one (1) answer.

1. Are you satisfied with the your overall experience at the enrollment center today?

Yes

No

2. If you experienced an issue that required a resolution, are you satisfied with the resolution?

Yes

No

3. Did the enrollment center representative(s) conduct themselves in a professional and courteous manner?

Yes

No

4. Are you satisfied with the enrollment center location and appearance?

Yes

No

NA

Thank you for participating. If you would like to provide additional feedback, please contact UES CUSTOMER SUPPORT at 855-DHS-UES1 (855-347-8371) or
use the ‘Contact Us’ link on the UES website at universalenroll.dhs.gov.

Key Pad Functions

1 = Yes

2 = No

3 = Not Applicable (NA)

Identity

Fee

Payment

7 = Move back to previous question

Biographics

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Disclosure

Survey

9 = Exit Survey

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Submit
1

EN 7/16/2013 @ 8:56 AM

Universal
Enrollment Services
Submit Enrollment
Access Agent’s TWIC

Place Right or Left Finger on Device

*PIN

******

Access

By placing my finger on the device,
I, STEVEN JONES, certify that the
information captured for John Smith
has been reviewed and verified.

Steven Jones

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Fee

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1

EN 7/16/2013 @ 8:56 AM

Universal
Enrollment Services
Submit Enrollment
Summary

Applicant:

JOHN S. SMITH

Known
UE
ID: Traveler Number:

U11F-193H9F
TBD

Service:

HME ENROLL

Fee:

$86.50

Paid:

$86.50

Method:

Website:
universalenroll.dhs.gov

CARD (1475)

Auth Number:

Date/Time:
Enrollment Location:
Notification Method:
Email Receipt to:

Customer Support:
855-DHS-UES1
(855-347-8371)

123ABC

07/16/2013 / 8:56 AM
UES Enrollment Center
1-615-123-4567
jsmith@comcast.net

Service

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Reprint

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Finish

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EN 7/16/2013 @ 8:56 AM

Universal
Enrollment Services
Submit Enrollment
Privacy Act and Paperwork Reduction Act Statements

PRIVACY ACT STATEMENT:
Authority: The authority for collecting this information is 49 U.S.C. 114, 114note, and 5103a.
Principal Purpose(s): This information is needed to verify your identity and to conduct a security threat assessment to evaluate your
suitability for the Hazardous Materials Endorsement Threat Assessment Program. Furnishing this information, including your SSN
or alien registration number, is voluntary; however, all information provided during the enrollment process assists in the timely
processing of your security threat assessment. Failure to provide it will delay and may prevent completion of your security threat
assessment.
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.
PAPERWORK REDUCTION ACT STATEMENT: Statement of Public Burden: This is a voluntary collection of information, but
failure to provide the information may result in an inability to approve your eligibility for the requested TSA program or benefit. TSA
estimates that the total average burden per response associated with this collection for enrollment 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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EN 7/16/2013 @ 8:56 AM


File Typeapplication/pdf
File TitleHME_workstation_comp.pdf
Authorklesuer
File Modified2013-08-21
File Created2013-08-21

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