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2. 
3. Employee Authorization Form
   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
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
    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