U.S. VIRGIN ISLANDS PORT AUTHORITY CYRIL E. KING AIRPORT ID BADGE APPLICATION COMPANY (TENANT) NAME LOCATION.f-s • tileMerril VT :TELEPHONE NO ID APPLICANT/REIQUESTOR NAME: PHISICAL ADDRESI MAILING ADDRESS TELEPHONE NO. (FIRST NAME) (MID .E !INITIAL) (I AST AME) SAME As AbasiE (II I PLACE OF BIRTH: Sl e e,, A'SCMZENSHIP. r • • PASSPORT ISSUING CONTRY SSNii HAIR COLOR. EYE COLOR SLLC RESIDENT ALIEN NO. SEX :MT Road V o re 0 DR I VIN PR II VILEDGE YES NO TERMINAL YES NO c 2 20 0 )( PASSPORT NO AOA: YES0 NO iA Requesting Supvr . /Mgr. Signature El 0 DATE By my signature and wathortud by the above employer (tenant) to execute taiga) this application, I hereby catty that based upon this compsoy's verification of the information entained withia this application, the information presented has bees determined to be true and accurate. As Its representative. I certify that the above employer (Mont) has obtained and will maintain a tea- year employment history and five-year employment verification, on file for the above applicant. I certify that the above company (tenant) will provide Information to the olDelala of the Transportation Security Administration (TSA) or Virgin Islands Port Authority (\TPA) upon request, to include applicable records of those employees who are terminated or whose access is no longer required. The above employer (tenant) agrees that should VIPA be fined by TSA for any security violation resulting from argligeoce by this employer (tenant) associated with this certification: the VIPA will place responsibility on the employer (truant) for reimbursement or direct payment to VIPA for nay floe levied for each violation. SIGNATURE OF EMPLOYER (TENANT) REPRESENTATIVE Name TITLE: DATE: MONTH DATE YEAR THIS CERTIFIES THAT I HAVE RECEIVED FROM THE PORT AUTHORITY A RESTRICTED AREA IDENTIFICATION BADGE/CARD ACCESS MEDIA. I UNDERSTAND THAT THE IDENTIFICATION BADGE/CARD MEDIA REMAINS THE PROP