City of Dallas s1
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SIGNATORY AUTHORIZATION APPLICATION City of Dallas, Department of Aviation tenant/lease holders must complete this application to obtain signatory authority at Dallas Love Field (DAL). In addition, lease holder companies may grant signatory authority to other sponsored companies by completing the Leaseholders Assurance of Sponsored Company section of this application. All signatory authorized individuals must comply with the Dallas Love Field Signatory Authorized requirements.
COMPANY INFORMATION COMPANY NAME: ______DEPT/DIV: ______ADDRESS:
______PHONE NUMBER: (_____) ______- ______FAX NUMBER: (_____) ______-______EMERGENCY TELEPHONE NUMBER (24hr.) (_____) ______-______SECURITY CONTACT PERSON: ______Please identify NO MORE than three (3) individuals authorized to sign the AIRPORT IDENTIFICATION MEDIA APPLICATION requesting the City of Dallas, Department of Aviation to issue an airport identification media. The Authorized Individual must complete all requirements and obtain approval from an Airport Security Coordinator (ASC) prior to becoming an Authorized Signatory. A new SIGNATORY AUTHORIZATION APPLICATION is required upon any changes to the Authorized Individuals listed below. AUTHORIZED INDIVIDUALS
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______NAME (PRINT OR TYPE) TITLE
SIGNATURE / DATE
______(_____) ______-______ASC APPROVAL ______DATE ______EMAIL PHONE NUMBER Train the Trainer ______
______
______NAME (PRINT OR TYPE) TITLE
SIGNATURE / DATE
______(_____) ______-______ASC APPROVAL ______DATE ______EMAIL PHONE NUMBER Train the Trainer ______
______
______NAME (PRINT OR TYPE) TITLE
AVI-FRM-679 Version 2 April 06, 2017 SIGNATURE / DATE
______(_____) ______-______ASC APPROVAL ______DATE ______EMAIL PHONE NUMBER Train the Trainer ______
LEASEHOLDER’S ASSURANCE OF SPONSORED COMPANY (PRINT OR TYPE) I, ______, ______, being an authorized official of (NAME) (TITLE) ______, a current lease holder/vendor with the City of Dallas, Department of (TENANT/LEASEHOLD COMPANY) Aviation, assures that all persons identified in this application are employed by ______(SPONSORED COMPANY) and its employees requiring unescorted access to the Secured/SIDA, Sterile, or AOA have or will complete the TSA requirements for their requested area of access, in accordance with 49 CFR Part 1542 and the DAL Airport Security Program. The assurances apply to the requirements for issuing the appropriate DAL media that will enable the Authorized Individuals of this application the ability to issue unescorted access to the vendor company employees at Dallas Love Field.
______AUTHORIZED SIGNATURE FOR LEASEHOLDER DATE
AVI-FRM-679 Version 2 April 06, 2017