Form DS-5539 Courier Employee Registration Form

U.S. Department of State

Courier Employee Registration Form

OMB CONTROL NO. 1405-XXXX
OMB EXPIRATION DATE: XX-XX-XXXX
ESTIMATED BURDEN: 40 MINUTES

NOTE: You must fill out the form in its entirety. If you have any questions regarding the form, please contact the National Courier Liaison at
NationalCourierLiaison@state.gov.

Part 1: To Be Filled Out By Employee
Company Name

Employee's Name (Last, First, Middle)

Company Address (Include Number, Street, City, State and Zip Code)

Company Email

Company Phone Number

By selecting the following boxes and signing below, you certify that all of the following statements are true.
You are at least 18 years of age.
You are a U.S. citizen or national, lawful permanent resident, or legally authorized to work in the U.S.
You have never been convicted of a felony.
You have never been convicted of a federal, state, or local misdemeanor related to the mismanaging of funds, identity theft, document fraud, or
a drug offense.
You are not currently under indictment or investigation for a felony or for any crime related to mismanaging funds, identity theft, document fraud,
or a drug offense.

NOTE TO THE EMPLOYEE: You must include a photocopy of the front and back of your government-issued photo identification.
I declare under penalty of perjury all of the following: 1) The statements above are true and correct, 2) I have not knowingly and willfully
made any false statements or provided false documents in support of this registration, and 3) I have read and understood the warning on
this form.

Signature of Courier Employee

Date

Part 2: To Be Filled Out By Courier Company Owner
Name

Title

Phone Number

Email

By selecting the following boxes and signing below, you certify that all of the following statements are true.
The company acknowledges that it bears responsibility for the employee's conduct pertaining to his/her duties associated with hand-carry passport
applications, supporting documentation, and/or passport products, in accordance with 22 C.F.R. 51.51 and Department guidance.
The company certifies that the employee has shown it appropriate documentation of U.S. citizenship and/or authorization to legally work in the
United States.

I declare under penalty of perjury all of the following: 1.) The statements above are true and correct, 2.) I have not knowingly and willfully
made any false statements or provided false documents in support of this registration, and 3.) I have read and understood the warning on
this form.

Signature of Courier Company Owner
DS-5539 XX-XXXX

Date
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WARNING
Knowingly and willfully providing false statements or documents in connection with this form is punishable by fine and/or imprisonment under U.S. law,
including provisions of 18 U.S.C. 1001. In addition, providing false information on this form or otherwise failing to abide by the requirements of the
procedures for passport couriers outlined in 22 C.F.R. Part 54 may result in the suspension, cancellation, or ban of an employee and/or the courier
company's registration to hand carry passport applications.

PRIVACY ACT STATEMENT
AUTHORITIES: Collection of the information on this form is authorized by Titles 8 and 22 of the United States Code, and other applicable laws and
regulations, including 22 U.S.C. 2651a et. seq.; 8 U.S.C. 1104; Executive Order 11295 (August 5, 1966); and C.F.R. Parts 50, 51, and 54.
PURPOSE: The primary purpose for soliciting this information is to determine the company's eligibility to register to perform hand carry services at
participating U.S. passport agencies pursuant to 22 C.F.R. Part 54.
ROUTINE USES: This information solicited on this form may be made available as a routine use to other government agencies for fraud prevention,
law enforcement, and administrative purposes. For a detailed listing of the routine uses for which this information may be disclosed, see the
Department of State's Prefatory Statement of Routine Uses relative to the Privacy Act (Public Notice 6290 of July 15, 2008) and the listing of routine
users set forth in then System of Records Notices and Passport Records (State-26) published in the Federal Registrar.

PAPERWORK REDUCTION ACT
Public reporting burden for this collection of information is estimated to average 40 minutes per response, including the time required for searching
existing data sources, gathering the necessary data, providing the information and/or documentation required, and reviewing the final collection. You
do not have to supply this information unless this collection displays a currently valid OMB control number. If you have comments on the accuracy of
this burden estimate and/or recommendations for reducing it, please send them to: U.S. Department of State, Bureau of Consular Affairs, Passport
Services, Office of Program Management and Operational Support, Attn: Passport Forms Officer, 44132 Mercure Cir., P.O. Box 1199, Sterling,
Virginia 20166-1199.

DS-5539 XX-XXXX

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