Fillable TSA- Form2808FINA Lv170105 Access Control Application - PIV/ Badge/ Credential

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TSA- Form2808FINA Lv170105 Access Control Application - PIV/ Badge/ Credential

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Previous editions of this form are obsolete.
TSA Form 2808 (10/16) rev. [File: 2800.8.3]
Page 1 of 4
DEPARTMENT OF HOMELAND SECURITY
Transportation Security Administration
ACCESS CONTROL APPLICATION – PIV/BADGE/CREDENTIAL
SECTION I: Application Type
(Select Applicable Fields)
First Name
Middle Initial
Social Security Number Date of Birth Gender
TSA Component or Government Agency
Office Address (Contractors Only)
City State Zip Code
Government Email Address Office Phone Number Cell Phone Number
Position
Access Location(s):
(Select Applicable Locations) (Not applicable for retired badge/credential)
SECTION III. Application
(Complete Applicable Fields)
Part A. PIV Card
Category
Replacement Reason
Designated Federal Emergency Response Official
(FERO)
(If yes is selected, approved DHS Form 1100-
27 & applicable addendum must be attached)
Designated Law
Enforcement
Officer (LEO)
PIV Card
Badge
Retired Badge Credential Retired CredentialMemorial Badge
Male Female
(Select One)
Contractor Federal Detailee Federal Employee
Other
TSA Headquarters
TSA Annapolis Junction
TSA Field Location (Airport Code)
TSA Walker Lane
Freedom Center
Transportation Security Integration Facility (TSIF)
OLE/FAMS Headquarters
Other
Access Change Only Change of Name New Replacement
Yes No
Yes No
Last Name
Contract Expiration Date
Entry on Duty Date
Application Date
Official Title
Contract Number
COR or Authorizing Official
OLE/FAMS Field Office
SECTION II: Applicant Information
Signature
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)
.
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Previous editions of this form are obsolete.
TSA Form 2808 (10/16) rev. [File: 2800.8.3]
Page 2 of 4
Replacement Reason:
Part C. Credential
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
Position or Title
TSA Component Government Email Address 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
requests.
Part A. BMO Director/Equivalent Information
Last, First, MI
Approved Date
TSA Component
Government Email Address
Office Phone
Cell Phone
Signature
Change of Position/Title New Replacement Retired
Memorial
Commemorative
Change of Name/Position/Title New Replacement Retired Memorial Card
Approved Date
Position or Title
Category
Category
Part B. Badge
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Previous editions of this form are obsolete.
TSA Form 2808 (10/16) rev. [File: 2800.8.3] Page 3 of 4
1. There was a determination made or action initiated to remove or proposal to remove, the employee
from Federal Employment;
2. There was an investigation or adjudication charge of misconduct against the employee that would have
led to the employee’s removal; or
3. The employees’ security clearance was suspended or revoked, or proposal to suspend or revoke the
clearance had been initiated or issued.
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. The employee was in good standing at the time of retirement (ref. responses above); and
3.
The employee retired consistent with the retirement definition in
TSA MD 2800.11, Badge and
Credential Program.
SECTION VII. Security Branch Use Only
Clearance Date
Status
Issue Date
Expiration Date Old PIV Card Number
Old PIV Card Returned?
Yes
No (explain in comments)
Was Lost/Stolen/Damaged PIV Card reported in accordance to TSA MD 2800.11, HB? (List Date)
Approved
No
Yes
If Disapproved, (explain)
Badge
Change of Position/TitleReplacementNew
Badge
Badge Type and Number
Tactical Badge Number
(if applicable)
Old Badge Number Old Badge Returned?
Yes
No (explain in comments)
Approved
Yes
No
If Disapproved, (explain)
Credential
New
Replacement
Change of Name/Position/Title
Credential Type Credential Number
Old Credential Number
Old Credential Returned?
No (explain in comments)
Yes
Was Lost/Stolen/Damaged Badge reported in accordance to TSA MD 2800.11, HB? (List Date)
Was Lost/Stolen/Damaged Credential reported in accordance to TSA MD 2800.11, HB? (List Date)
Approved
If Disapproved, (explain)
Yes
No
Yes No
Yes
No
Yes
No
Yes
No
No
Yes
Yes
No
Security Clearance
PIV Card
TS/SCI
TS S
Other
Part B. Good Standing Determination
ReplacementNew
Change of Name/Position/Title
Signature
Signature
4.
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.
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Previous editions of this form are obsolete.
TSA Form 2808 (10/16) rev. [File: 2800.8.3] Page 4 of 4
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.
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TSA- Form2808FINA Lv170105 Access Control Application - PIV Badge Credential

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Completed 23 July 2020

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