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Employee Authorization Form

2. 

3. Employee Authorization Form
   Completed by Authorized Signatory Only

   Completed by Authorized Signatory Only

7. First Name of Authorized Signatory

8. Last Name of Authorized Signatory

10. Organization

11. Phone Number

13. Email Address

17. Badge Applicant Information

19. Badge Type

    1. AOA
    2. SIDA
    3. Cargo SIDA
    4. Concessionaire SIDA

23. First Name

24. Middle Name

25. Last Name

27. Address

29. City

30. State

31. Zip Code

33. Phone Number

34. Email Address

36. Applicant's Employer

37. Reasons for Requesting Access

41. I-9 Document Verification
    Please see "Badge Identification Requirements" Document

    Please see "Badge Identification Requirements" Document

43. Was Applicant born outside the U.S.?*

    1. Yes
    2. No

44. Applicant was born outside the U.S., has a VALID passport, Certificate of Birth Abroad or Certificate of Naturalization and Social Security Card and can provide these items.*

    1. I confirm

46. Is Applicant a United States Citizen? *

    1. Yes
    2. No
47. Applicant is NOT a U.S. Citizen. *

    Applicant will present Foreign Passport and Form I-94 or Permanent Resident Card.

    1. I confirm
49. I hereby certify that the above named applicant will abide by TSA and Minot International Airport security regulations. I further certify that the organization I represent assumes all responsibility for all fines, or other penalties imposed by the TSA upon the Minot International Airport for any violation(s) by this applicant. Furthermore, if movement area access is requested, I certify that the applicant has received the appropriate training as it relates to ground vehicle operations regulations and in relation to the level of job responsibilities that they will perform. I certify that I will collect the unescorted access identification media from the employee immediately upon termination of his/her unescorted access and return the badge to Airport Administration within five (5) days.

51. By checking the "I agree" box below, you agree and acknowledge that:*

    1) Your application will not be signed in the sense of a traditional paper document,
    2) By signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and
    3) You may still be required to provide a traditional signature at a later date.

    1. I agree
53. Authorized Signatory's Signature*

54. Date*
    Date

56. Airport Badging Office
    305 Airport Road<br> Suite 216<br> Minot, ND 58703<br> Phone: 701-857-4724

    305 Airport Road
    Suite 216
    Minot, ND 58703
    Phone: 701-857-4724

Leave This Blank:


58. 1. Receive an email copy of this form.
59. Email address

    This field is not part of the form submission.

60. Submit

* indicates a required field