Cbp Access Form

UNITED STATES CUSTOMS AND BORDER PROTECTION ACCESS – JFK AIRPORT NOTICE: THIS FORM DOES NOT REPRESENT TEMPORARY ACCESS TO WORK IN ZONE 1 OR ZONE 2, NOR MAY IT BE EXCHANGED FOR AN FIS VISITOR’S PASS K#:______________________________

TO BE COMPLETED BY COMPANY: DATE:______________________________

EMPLOYEE NAME:______________________________, ________________________________, __________ (Last)

(First)

(Middle)

EMPLOYEE SOCIAL SECURITY #:_________________________________________ SEX: Male

Female

DATE OF BIRTH:________________________________ POSITION:______________________________________ ADDRESS: _____________________________________________________________________________ HAVE YOU EVER BEEN CONVICTED OF ANY CRIME OR OFFENSE (other than traffic violation, you may exclude any items which occurred before your 16th birthday) IN THIS COUNTRY OR ELSEWHERE? YES explain if yes NO EXPLANATION OF ALL CONVICTIONS (Federal, State, Military or Foreign)

EMPLOYEE SIGNATURE COMPANY NAME:_______________________________________________________________________ COMPANY ADDRESS:____________________________________________________________________ COMPANY ISSUING OFFICER:____________________________________________________________ COMPANY ISSUSING OFFICER SIGNATURE:______________________________________________ COMPANY ISSUING OFFICER PHONE #:(_______)___________

_____________

TO BE COMPLETED BY U.S. CUSTOMS AND BORDER PROTECTION: AUTHORIZED CBP ACCESS RENEWAL

ADDITION

DELETION

ZONE 1

ZONE 1

ZONE 1

ZONE 2

ZONE 2

ZONE 2

(Authorized Signature on file with Port Authority) WILL NOT BE ACCEPTED WITHOUT CBP VALIDATION AND SIGNATURE