Form TSA Form 2214 TSA Form 2214 HTAP Application

HTAP Application

INSTRUCTIONS: If you would like to obtain a Hazardous Materials Endorsement (HME) for your commercial driver’s license, you are required to complete a HME Threat Assessment Program (HTAP) application. To undergo this assessment, all applicants must provide information requested below and the appropriate documentation to verify their identity and immigration status as part of the application process. Completed forms (including an applicant’s signature) must be submitted in person at the beginning of the application process. Applicants are encouraged to take their time and review all information included on the form. Please confirm your eligibility before applying by reviewing Section VII “Eligibility Requirements” on page 3. If you are initially disqualified, you may be eligible for a 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 an Initial Determination of Threat Assessment (IDTA) letter before applying for an appeal or a waiver. All fields are required unless otherwise noted.

SECTION I -- 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 Yes No threat assessment?		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 Yes No Cargo Screening, Indirect Air Carrier, TWIC, FAST, MMD, etc.)?		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, Yes No in any jurisdiction, military or civilian, in the last 7 years before the date of this application?
2. Have you been released from incarceration in any jurisdiction, military or civilian, for committing any disqualifying felony Yes No listed in Section 1, Part A, in during the 5 years before the date of this application?
3. Have you been convicted, or found not guilty by reason of insanity, of any disqualifying felony listed in Section 1, Part B, Yes No in any jurisdiction, military or civilian?
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 Yes No mental institution?
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: DSP-150, Border Crossing Card I-688A or I-766, Employment Authorization Card I-94, Arrival/Departure Record I-688B, Employment Authorization Document I-151 or I-551, Permanent Resident Card I-872, American Indian Card I-197 or I-179, U.S. Citizenship ID Card I-873, Northern Mariana Card I-327, Re-entry Permit N-550 or N-570, Certificate of Naturalization I-571, Refugee Travel Card N-560 or N-561, Certificate of U.S. Citizenship I-688, Temporary Resident Card U.S. Birth Certificate

SECTION VII -- 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. Voluntary manslaughter

16. 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 (fiancé(e)) lawful nonimmigrant status); or

   4. An alien in valid K–2 (Minor child of fiancé(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: 6 U.S.C. § 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 110-52, August 3, 2007); and Executive Order 9397, as amended. Purpose: The Department of Homeland Security (DHS) will use your information to conduct a security threat assessment. Your fingerprints and associated information will be provided to the Federal Bureau of Investigation (FBI) for the purpose of comparing your fingerprints to other fingerprints in the FBI’s Next Generation Identification (NGI) system or its successor systems including civil, criminal, and latent fingerprint repositories. The FBI may retain your fingerprints and associated information in NGI after the completion of this application and, while retained, your fingerprints may continue to be compared against other fingerprints submitted to or retained by NGI. DHS will also transmit your fingerprints for enrollment into Automated Biometrics Identification System (IDENT). If you provide your Social Security Number (SSN), DHS may provide your name and SSN to the Social Security Administration (SSA) to compare that information against SSA records to ensure the validity of the information. 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 pursuant to 5 U.S.C. 522a(b)(3) including with third parties during the course of a security threat assessment, employment investigation, or adjudication of a waiver or appeal request to the extent necessary to obtain information pertinent to the assessment, investigation, or adjudication of your application or in accordance with the routine uses identified in the TSA system of records notice (SORN) DHS/TSA 002, Transportation Security Threat Assessment System, or DHS/TSA 021, TSA Pre✓® Application Program for applicants to that program. Records may be disclosed to contractors and their agents, grantees, experts, consultants, and others performing or working on a contract, service, grant, cooperative agreement, or other assignment for DHS, when necessary to accomplish an agency function related to this system of records. For as long as your fingerprints and associated information are retained in NGI, your information may be disclosed pursuant to your consent or without your consent as permitted by the Privacy Act of 1974 and all applicable Routine Uses as may be published at any time in the Federal Register, including the Routine Uses for the NGI system and the FBI’s Blanket Routine Uses. Disclosure: Furnishing this information (including your SSN) is voluntary; however, if you do not provide your SSN or any other information requested, DHS may be unable to complete your application for a security threat assessment. 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.

TSA Form 2214, 09/2016 [File: 2200.5.1-b]

Page 2 of 3

OMB No. 1652-0027 Expires: 01/31/2017