APPLICATION FOR NEW OR RENEWAL SECURITY THREAT ASSESSMENT (STA)

APPLICATION FOR NEW OR RENEWAL SECURITY THREAT ASSESSMENT (STA)
Are you applying to work on behalf of DAVIS or an Independent Contractor?*

Davis Trucking, LLCIndependent Contractor
Independent Contractor Name
All fields are to be completed unless otherwise noted.

SECTION I. General Information
Legal Name As it appears on your IDs *
First
Middle NameLast NameSuffix
Previous Name Used (If Applicable)

First NameMiddle NameLast NameSuffix
Previous Name Used (If Applicable)

First NameMiddle NameLast NameSuffix
Social Security Number *
Email Address *
Date of Birth (MM/DD/YYYY)*

MonthDayYear
Date
Gender:*

MaleFemale
Phone Number*
Place of Birth (City AND State)
City, State (Ex: San Diego, CA)
Place of Birth*

CityStateCountry
Country of Citizenship*
US Passport Number or Certificate of Birth Abroad Number (If Applicable)
Alien Registration Number (If Applicable)
Naturalization Date (If Applicable)

MonthDayYear
Date
Naturalization Certificate Number (If Applicable)
Current Mailing Address*
City*
State*
Country*
Zip Code*
Current Residential Street Address*

Same As MailingOther
City*
State*
Country*
Zip Code*
Start Date at this Address*

MonthDayYear
Date
End Date at this Address ( pick today if current)*

MonthDayYear
Date
Previous Residential Address (If Applicable, See Instructions):

PLEASE MAKE SURE TO PROVIDE AT LEAST 5 YEARS OF RESIDENCY INFORMATION
Previous Street Address #1
City
State
Country
Zip Code
Start Date at this Address

MonthDayYear
Date
End Date at this Address

MonthDayYear
Date
Previous Residential Address (If Applicable, See Instructions):
Previous Street Address #2
City
State
Country
Zip Code
Start Date at this Address

MonthDayYear
Date
End Date at this Address

MonthDayYear
Date
All fields are to be completed unless otherwise noted.

Previous Residential Address, Five years of residency is required. If you have already listed 5 years of residential information above, you can skip to the signature section below.
Previous Street Address #3
City
State
Country
Zip Code
Start Date at this Address

MonthDayYear
Date
End Date at this Address

MonthDayYear
Date
Previous Street Address #4
City
State
Country
Zip Code
Start Date at this Address

MonthDayYear
Date
End Date at this Address

MonthDayYear
Date
SECTION II. Applicant Acknowledgement

This information I have provided on this application is true, complete, and correct to the best of my knowledge and belief and is provided in good faith, I understand that a knowing and willful false statement, or an omission of a material fact, on this application can be punished by fine or imprisonment or both (see section 1001 of Title 18 United States Code), and may be grounds for denial of authorization or in the case of parties regulated under this section, removal of authorization to operate under this chapter, if applicable. I acknowledge that if I do not successfully complete the Security Threat Assessment (STA), the Transportation Security Administration (TSA) may notify my employer. If TSA or other law enforcement agency becomes aware that I may pose an imminent threat to an operator or facility, TSA may provide limited information necessary to reduce the risk of injury or damage to the operator or facility.
Applicant Signature*

Clear
Date*

MonthDayYear
Date
Employer Name
Corp Address
City
State
Zip Code
Employer Phone #
Should be Empty: