Free CBP Form 3078 - Application for Identification Card - Federal

DEPARTMENT OF HOMELAND SECURITY

U.S. Customs and Border Protection APPLICATION FOR IDENTIFICATION CARD
19 U.S.C. 66, 1551, 1555, 1565, 1624, 1641; 19 CFR 112.42, 118, 122.182, 146.6 1. TYPE OF ACTIVITY REQUIRING IDENTIFICATION CARD
Cartman/ Lighterman Broker's Employee CBP Security Area Identification Warehouse Officer or Employee Container Station Employee Foreign Trade Zone Employee CES Employee OMB No.1651-0008 Exp. 09-30-2009

2. DATE OF THIS APPLICATION

3. NAME (Last, First, & Middle) 5. LIST ANY OTHER NAMES YOU HAVE EVER BEEN KNOWN BY (Nicknames, aliases, etc.) 7. HOME ADDRESS (Number, Street, City, State, and ZIP Code)

4. SOCIAL SECURITY NUMBER 6. DATE OF BIRTH

8. NAME AND ADDRESS OF PRESENT EMPLOYER

9. HOME PHONE NUMBER 11. PLACE OF BIRTH (City, County, State, and Country) 16. VISIBLE SCARS OR MARKS 17. U.S. COAST GUARD PORT SECURITY CARD NUMBER

10. BUSINESS PHONE NUMBER 12. HEIGHT 13. WEIGHT 14. COLOR HAIR 15. COLOR EYES

18. U.S. MERCHANT MARINE CARD NUMBER

19. HAVE YOU EVER APPLIED FOR CARD IN ITEM 17 OR ITEM 20. HAS APPLICATION FOR EITHER CARD IN ITEM 17 OR 18 BEEN 18? DENIED?
YES NO (Skip Items 20 and 21) YES (If Yes, explain in Item 21) NO (Skip Item 21)

21. EXPLANATION OF APPLICATION DENIAL 22. LIST ALL RESIDENCES DURING THE LAST 5 YEARS (List in reverse order, beginning with the present address) DATES From To PRESENT Number and Street City State

23. HAVE YOU EVER SERVED IN THE ARMED SERVICES OF THE U.S.?
YES NO (Skip Items 24-28)

24. BRANCH OF SERVICE 26. SERIAL NUMBER 27. TYPE OF DISCHARGE

25. DATES OF SERVICE

28. IF DISCHARGE WAS OTHER THAN HONORABLE, EXPLAIN IN FULL DETAIL

29. HAVE YOU EVER APPLIED FOR AN IDENTIFICATION CARD WITH U.S. CUSTOMS AND BORDER PROTECTION?

YES

(If Yes, explain details)

NO

CBP Form 3078 (04/08)

30. PREVIOUS EMPLOYMENT -- LIST IN CHRONOLOGICAL ORDER, GIVING EARLIEST EMPLOYMENT FIRST (Last 10 Years) DATES From To EMPLOYER NAME AND ADDRESS OCCUPATION

31. HAVE YOU EVER BEEN CONVICTED OF ANY CRIME OR OFFENSE (Other than traffic violations, you may exclude any items which occurred before your 16th birthday) IN THIS COUNTRY OR ELSEWHERE? 32. EXPLANATION OF ALL CONVICTIONS (Federal, State, Military, or Foreign)

YES (If YES, explain in Item 32.)

NO

Date

Place

Charge

Court

Final Disposition

33. DO YOU NOW USE OR HAVE YOU EVER USED NARCOTIC DRUGS?

YES (If YES, explain below.)

NO 34. ATTACH PHOTOGRAPH HERE

35. CERTIFICATION

I certify that all of the statements made in this Application are true, complete, and correct to the best of my knowledge and belief, and are made in good faith.

SIGNATURE

DATE

X

Paperwork Reduction Act Notice: The Paperwork Reduction Act says we must tell you why we are collecting this information, how we will use it, and whether you have to give it to us. We ask for this information to carry out U.S. Customs and Border Protection laws of the United States. This form is used by licensed cartmen or lightermen or their employees as an application to apply for a CBP identification card and is required to obtain or retain a benefit. The estimated average burden associated with this collection of information is 17 minutes per respondent or recordkeeper depending on individual circumstances. The valid OMB Control Number for this Information Collection is 1651-0008. Pursuant to the requirements of Public law 93-579 (Privacy Act of 1974), notice is hereby given that the authority to collect information on CBP Form 3078 is 5 U.S.C. 301, Reorganization Plan No. 1 of 1950; 19 U.S.C. 1551, 1565, 1624, 1641; 19 CFR 112.42. The principal purpose for collecting the information is to enable CBP to conduct a background investigation and thereby determine whether the applicant meets the criteria required for the issuance of an identification card. The information collected and contained in the applicant's file may be provided to those employees of CBP who have a need for the records in the performance of their duties. The information may also be used, when deemed appropriate, in a proceeding to revoke or suspend the identification card. Disclosure of all information requested on CBP Form 3078 is voluntary; however, failure to disclose some or all of this information may result in CBP's inability to conduct the required background investigation.

CBP Form 3078 (04/08)