Form TSA Form 2808 TSA Form 2808 Access Control Application PIV/Badge/Credential

DEPARTMENT OF HOMELAND SECURITY

Transportation Security Administration
ACCESS CONTROL APPLICATION – PIV/BADGE/CREDENTIAL
INSTRUCTIONS: (1) TSA employees, contractors, detailees, and other Federal employees who require access control identification card
i.e, Personal Identity Verification (PIV) card to gain access to TSA controlled facilities must complete this form and submit to mailbox
PIVACO@tsa.dhs.gov. (2) Employees requiring a badge and/or credential to identify and describe the bearer's right to exercise specific
authority to perform specific official functions shall also use this form to submit their application. Specify "N/A" or "Unknown" for any
information that cannot be provided. The completed form must be attached and emailed to the individual FSD, SAC or equivalent to
the appropriate Organizational Element/Point of Contact (OE/POC) for approval. If approved, the OE/POC will send the completed form
to the Security Branch at CredentialBadgeCustS@tsa.dhs.gov. This form must be completed in accordance with TSA MD 2800.11, Handbook
(HB).
SECTION I: Application Type (Select Applicable Fields)
PIV Card

Badge

Retired Badge

Memorial Badge

Credential

Retired Credential

SECTION II: Applicant Information

Last Name

Middle Initial

First Name
Male

Social Security Number

Application Date

Date of Birth

Gender

Entry on Duty Date

Official Title

TSA Component or Government Agency

Office Address (Contractors Only)

City

Government Email Address

Office Phone Number

Female

State

Zip Code

Cell Phone Number

Position
(Select One)

Contractor

Federal Detailee

Federal Employee

Other

Access Location(s): (Select Applicable Locations) (Not applicable for retired badge/credential)
TSA Headquarters

TSA Annapolis Junction

TSA Field Location (Airport Code)

TSA Walker Lane

Freedom Center

Transportation Security Integration Facility (TSIF)

OLE/FAMS Headquarters

OLE/FAMS Field Office

Other

SECTION III. Application (Complete Applicable Fields)
Part A. PIV Card
Category

Access Change Only

Change of Name

New

Replacement

Replacement Reason
Designated Federal Emergency Response Official
(FERO) (If yes is selected, approved DHS Form 1100-

27 & applicable addendum must be attached)

COR or Authorizing Official
Signature

TSA Form 2808 (10/16) rev. [File: 2800.8.3]

Yes

No

Designated Law
Enforcement
Officer (LEO)

Contract Number

Previous editions of this form are obsolete.

Yes

No

Contract Expiration Date

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Part B. Badge
Change of Position/Title

Category

New

Replacement

Retired

Memorial

Commemorative

Replacement Reason:
Part C. Credential
Category

Change of Name/Position/Title

New

Replacement

Retired

Memorial Card

Replacement Reason:
Official Title (refer to SF50, Notice of Personnel Action)
Part D. Retired Badge or Credential Waiver/Acknowledgement
The TSA retired badge and/or credential does not confer powers [law enforcement or non-law enforcement] or authorize engagement in any
law enforcement activities and investigations. I waive the right to make a claim of any description to include claims, actions, suits, procedures,
costs, expenses, damages, and liabilities against TSA resulting from the authority to carry retired badge and/or credentials.
I acknowledge that I have read and understand the information provided above.
Signature
SECTION IV. Responsibilities Acknowledgement
In accordance with Homeland Security Presidential Directive 12 (HSPD-12) DHS MD 11020.1, Issuance of Access Control Media, DHS
Instruction 121-01-002, Issuance and Control of DHS Badges, DHS Instruction 121-01-008, Issuance and Control of DHS Credentials and
TSA MD 1100.73-5, Addressing Unacceptable Performance and Conduct, the electronic submission of this form constitutes an agreement to
comply fully with all requirements in the use, display and control of accountable property.
Ensure proper handling and safeguarding, to include not lending, giving or allowing another person to use such property for any
purpose;
Do not store this property in your vehicle;
Employ such property only in the performance of official duties;
Return the property to the Accountable Property Official (APO), or upon demand by other designated TSA Official when no longer
required for the purpose intended and upon separation from the government;
Report any property that is lost, stolen, damaged, destroyed or otherwise compromised within 24 hours upon discovery to the TSOC,
PARIS, and local PD, or to the TSA HQs Command Center (571-227-2600) who will make notifications for you; and
Accept administrative review/action if the property is lost, stolen, damaged, destroyed or otherwise misused as a result of willful intent or
gross negligence.
I acknowledge that I have read and understand the information provided above.
Signature
SECTION V. Supervisor Information

(Unit Chief and Above Use Only)

Last, First, MI

TSA Component

Position or Title
Government Email Address

Approved Date
Office Phone

Cell Phone

Signature
SECTION VI. BMO Director/Equivalent Use Only All requests complete Part A. Parts B & C must also be completed for Retired Badge & Credential
Part A. BMO Director/Equivalent Information

Last, First, MI

TSA Component

requests.

Approved Date

Position or Title

Government Email Address

Office Phone

Cell Phone

Signature

TSA Form 2808 (10/16) rev. [File: 2800.8.3]

Previous editions of this form are obsolete.

Page 2 of 4

Part B. Good Standing Determination
1.

There was a determination made or action initiated to remove or proposal to remove, the employee
from Federal Employment;

Yes

No

2.

There was an investigation or adjudication charge of misconduct against the employee that would have
led to the employee’s removal; or

Yes

No

3.

The employees’ security clearance was suspended or revoked, or proposal to suspend or revoke the
clearance had been initiated or issued.

Yes

No

Signature
Part C. Service Eligibility
1. The employee completed five (5) years of service with TSA [exception; the LEO transferred into TSA
directly from another Federal agency and the total amount of Federal law enforcement is five years or
more regardless of the amount of time completed in TSA. Non-LEOs must have accrued a total of five
years of Federal service to meet this exception}; and
2.
3.
4.

The employee was in good standing at the time of retirement (ref. responses above); and
The employee retired consistent with the retirement definition in TSA MD 2800.11, Badge and
Credential Program.

Yes

No

Yes

No

Yes

No

I have reviewed the criteria with the appropriate offices and I find the employee:
Meets all criteria and is eligible for a retired badge and/or credential. (Requires "YES" response on 1, 2, and 3)
Does not meet all of the above criteria and is not eligible for a retired badge and/or credential.

Signature
SECTION VII. Security Branch Use Only
Security Clearance
PIV Card

TS/SCI

New

Replacement

TS

Other

S

Clearance Date

Change of Name/Position/Title

Status

Issue Date

Expiration Date

Old PIV Card Number

Yes

Old PIV Card Returned?

No (explain in comments)

Was Lost/Stolen/Damaged PIV Card reported in accordance to TSA MD 2800.11, HB? (List Date)

Yes

Approved
Badge

New

No

Replacement

If Disapproved, (explain)
Change of Position/Title

Badge Type and Number

Tactical Badge Number (if applicable)

Old Badge Number

Old Badge Returned?

Yes

No (explain in comments)

Was Lost/Stolen/Damaged Badge reported in accordance to TSA MD 2800.11, HB? (List Date)

Yes

Approved
Credential

New

No
Replacement

If Disapproved, (explain)
Change of Name/Position/Title

Badge
Credential Type

Credential Number

Old Credential Number

Old Credential Returned?

Yes

No (explain in comments)

Was Lost/Stolen/Damaged Credential reported in accordance to TSA MD 2800.11, HB? (List Date)
Approved

Yes

No

TSA Form 2808 (10/16) rev. [File: 2800.8.3]

If Disapproved, (explain)
Previous editions of this form are obsolete.

Page 3 of 4

Comments
Name (Approving Official)

Title

Date

Signature
PRIVACY ACT STATEMENT: AUTHORITY: Executive Order 9397; Presidential Memorandum on Upgrading Security at Federal Facilities,
June 28, 1995; Homeland Security Presidential Directive 12, August 27, 2004; 49 U.S.C. 114 (f). PURPOSE(S): The information, including your
Social Security Number, is needed to process your access control application for a Personal Identity Verification Card (PIV), badge or credential
used to access federally controlled facilities and/or information systems.
ROUTINE USE(S): Information you provide will be disclosed to
individuals within DHS with a need to know the information in the performance of official duties in accordance with Privacy Act, 5, U.S.C 552a
and in accordance with routine uses listed in DHS/ALL-026, Personal Identity Verification Management System Systems of Records.
DISCLOSURE: Voluntary; however, failure to do so may affect your ability to access federally controlled facilities and/or information systems in
order to perform work-related activities.

TSA Form 2808 (10/16) rev. [File: 2800.8.3]

Previous editions of this form are obsolete.

Page 4 of 4