APPLICATION FOR AIRPORT RESTRICTED AREA PASS ALL INFORMATION TO BE ENTERED IN BLOCK CAPITALS

Transcription

1 Page 1 of 6 Assigned RAP#: APPLICATION FOR AIRPORT RESTRICTED AREA PASS ALL INFORMATION TO BE ENTERED IN BLOCK CAPITALS TYPE OF PASS: PERMANENT TEMPORARY PROXY CARD PERSONAL INFORMATION: SURNAME: DATE OF APPLICATION: FIRSTNAME: MIDDLE NAME (S): ALIASES/ NICKNAME (S): SEX: M: F: DATE OF BIRTH: YEAR: MONTH: DAY: PLACE OF BIRTH: (DISTRICT AND PARISH) NATIONALITY: TRN #: NIS #: ADDRESS & INFORMATION: PERMANENT ADDRESS: CITY/TOWN: PARISH: POST OFFICE/ ZIP CODE: COUNTRY: HOME TEL. #: CELL # 1: CELL # 2: CELL # 3: ADDRESS: TEMPORARY ADDRESS: CITY/TOWN: PARISH: POST OFFICE/ ZIP CODE: COUNTRY: FATHER S NAME AND ADDRESS: MOTHER S NAME AND ADDRESS:

2 Page 2 of 6 APPLICANT S PLACES OF RESIDENCE IN THE LAST FIVE YEARS : BIOLOGICAL INFORMATION: HEIGHT: WEIGHT: HAIR COLOUR: EYE COLOUR: IDENTIFYING MARKS: OCCUPATIONAL INFORMATION: CURRENT EMPLOYER: CURRENT OCCUPATION: PREVIOUS EMPLOYER: EMPLOYMENT HISTORY: (EMPLOYERS MUST INDICATE MEANS OF VERIFICATION BY PLACING A CHECKMARK IN THE APPROPRIATE COLUMN) P = verified in person; D = verified by documents; T = verified by telephone VERIFICATION MEANS EMPLOYER ADDRESS & NUMBER PERIOD EMPLOYED PERSON DATE OF P D T ACADEMIC/ PROFESSIONAL INFORMATION: (EMPLOYERS MUST INDICATE MEANS OF VERIFICATION BY PLACING A CHECKMARK IN THE APPROPRIATE COLUMN) P = verified in person; D = verified by documents; T = verified by telephone SCHOOLS/ TERTIARY INSTITUTIONS ATTENDED PERIOD ATTENDED ADDRESS & NUMBER VERIFICATION PERSON DATE OF MEANS P D T

3 Page 3 of 6 VERIFICATION OF APPLICANT S IDENTIFICATION: USE ANY TWO OF THE FOLLOWING AND GIVE NUMBER PASSPORT #: DRIVERS LICENSE #: VOTER ID #: COMPANY ID #: SCHOOL ID #: PHOTO CERTIFIED BY JUSTICE OF THE PEACE (JP) NAME OF JUSTICE OF THE PEACE : ID NUMBER OF JUSTICE OF THE PEACE: POLICE RECORD INFORMATION: POLICE RECORD DATE: YEAR: MONTH: CRIMINAL CONVICTION: YES: NO: IF YES PLEASE PROVIDE DETAILS: DAY: POLICE RECORD ATTACHED: YES: NO: ADDITIONAL INFORMATION: DECLARATION OF APPLICANT: I THE UNDERSIGNED, CERTIFY THAT THE INFORMATION I HAVE SUPPLIED IS TRUE. I UNDERSTAND THAT IF ANY OF THE ABOVEMENTIONED INFORMATION IS FALSE, OR SHOULD IT BE DISCOVERED I HAVE OMIT- TED ANY OTHER PERTINENT INFORMATION THAT MAY AFFECT THE ISSUANCE OF A RESTRICTED AREA PASS, MY APPLICATION MAY BE DENIED AND I MAY BE SUBJECT TO DISCIPLINARY PROCEEDINGS AND/ OR CRIMINAL CHARGES. I AM AWARE AND AGREE THAT I WILL BE SUBJECT TO EMPLOYMENT HISTORY VERIFICATION AND CRIMINAL RECORDS CHECK. APPLICANT SIGNATURE DATE

4 TO BE COMPLETED BY AUTHORIZED COMPANY OFFICER Page 4 of 6 RESTRICTED AREAS (TICK AREAS WHERE ACCESS IS BEING REQUESTED): T1: Customs Hall T2: Immigration Hall T3: Departure Lounge T4: Tower Block T5: Mezzanine Level T6: Departure Piers & Finger S1: Fuel Farm S3: Tech Ops S2: Transportation Hall Extension S4: Sewage Farm & Water Storage Area S5: Energy Centre S6: Versair Food Processing Plant, MOA Fumigation Centre, Cargo Village, Nav. Aid Facility, Sports Club and former Air Jamaica Delayed Baggage Centre JUSTIFICATION FOR RESTRICTED AREA PASS (State duties performed within restricted areas): DECLARATION OF EMPLOYER: I THE UNDERSIGNED, CERTIFY THAT THE INDIVIDUAL EMPLOYEE HISTORY INVESTIGATION AND CRIMI- NAL RECORD CHECK HAVE BEEN COMPLETED, AND ALL OTHER APPROPRIATE INVESTIGATIONS CON- DUCTED AND ACCEPTED, IN ACCORDANCE WITH THE STATUTORY REQUIREMENTS GOVERNING SUCH INVESTIGATIONS; AND THAT NOTHING ARISING FROM THESE INVESTIGATIONS WOULD RENDER THE AP- PLICANT INELIGIBLE OR UNSUITABLE FOR THE ISSUANCE OF A RESTRICTED AREA PASS. Company Authorized Officer s Name: Company Authorized Officer s Signature: Date: Place Company Stamp Here:

5 TO BE COMPLETED BY APPLICANT Page 5 of 6 TERMS OF ISSUE AS A HOLDER OF A RESTRICTED AREA PASS I UNDERSTAND, AGREE TO AND WILL ABIDE BY THE FOL- LOWING TERMS OF ISSUE: (a) that the Pass issued to me is the property of the NMIA Airports Ltd.; (b) that I will safeguard the Pass at all times and report the loss or theft of the Pass without delay to the issuing authority. (c ) that I will not permit unauthorized use of the Pass; (d) that I will wear/display the Restricted Area Pass at all times when I am in a Restricted Area; it will be worn on either the chest, breast (above the waist line) or front upper arm with picture and expiration date facing forward. (e) that I will not knowingly and willingly assist a person not in possession of a valid Restricted Area Pass to gain entrance into a Restricted Area; (f) that I will surrender the Restricted Area Pass on termination of employment or on demand of the issuing authority or a member of the Airport Security Staff. (g) I understand the Pass issued to me is only valid while I am on duty or in the performance of functions directly duty related, within the areas in which I work. I will not use the Pass to access Restricted Areas for personal reasons. (h) I will not use the pass issued to me to bypass or attempt to bypass security access control measures. I will submit all my belongings, vehicle as well as my person to any approved screening being conducted by security or other persons authorized so to do. (i) That if, subsequent to the issue of this pass, I am arrested or convicted of any crime in any jurisdiction, I will within 24 hours report this arrest or conviction to the Director, Aviation Security and surrender the restricted area pass to the Aviation Security Department. I CERTIFY THAT A. I HAVE RECEIVED THE PASS DESCRIBED ON PAGE 6 (PLEASE TURN OVER) B. I HAVE READ, UNDERSTAND AND AGREE TO COMPLY WITH THE TERMS OF ISSUE PRINTED ABOVE SIGNATURE DATE PLEASE TURN OVER

6 Page 6 of 6 FOR PASS CONTROL USE ONLY TYPE OF PASS: PERMANENT TEMPORARY (UNESCORTED) POLICE RECORD ATTACHED: RAP No: APPROVED NOT APPROVED YES NO RAP ISSUE DATE: DATE OF RECORD: AREAS GRANTED: A1 A2 A3 T1 T2 T3 T4 T5 T6 S1 S2 S3 S4 S5 S6 RAP EXPIRY DATE: PROXY CARD INFO. CARD #: PIN #: PASS BACKGROUND COLOUR: ADDITIONAL INFORMATION OR REMARKS AVIATION SECURITY AWARENESS TRAINING YES NO DATE OF TRAINING: TEST SCORE: % PASS ISSUE AUTHORISATION NAME OF ISSUING AGENT: SIGNATURE: NAME OF LEAD AGENT: SIGNATURE: NAME OFAVIATION SECURITY MANAGER/ DIRECTOR: SIGNATURE: RANDOM VERIFICATION RECORD EMPLOYMENT HISTORY VERIFICATION FINDINGS: NAME OF AGENT: SIGNATURE DATE OF RANDOM VERIFICATION: