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SENSITIVE SECURITY INFORMATION Initial Release January 8 2007 Date Change Posted July 1 2010 Date Effective July 31 2010 Indirect Air Carrier Standard Security Program ATTACHMENT 1 AVIATION SECURITY KNOWN SHIPPER VERIFICATION ASKSV FORM Print clearly in all fields except for signatures. The form must be completed in its entirety. Once completed this form is not considered Sensitive Security Information* Section 1. Facility and Contact Data Date of physical visit / Name of business visited Also doing business as trade name Business type Employer s Identifying Number Number of years in business Name of individual contacted Title Section 2. Address Information Physical address City State Zip Mailing address if different Section 3. Shipper s Contact Information Physical location phone number Principal contact phone number Emergency phone number Fax number Email address Web address Section 4. Verifier s Information Name title of employee or authorized representative verifying the above information Name of aircraft operator/ foreign air carrier/ or indirect air carrier Phone number I certify the above information is true and correct and the onsite visit and verification was conducted in person as required by the TSA standard security program and applicable security directives. This certification is i made with the understanding that any intentional falsification may be subject to both civil and criminal penalties under 49 CFR 1540. 103 and 18 U*S*C. 1001 and ii subject to record keeping requirements approved by TSA. Signature of Verifier Signature of Shipper TSA FORM 419H IACSSP Change 5 Effective Date July 31 2010 WARNING THIS RECORD CONTAINS SENSITIVE SECURITY INFORMATION THAT IS CONTROLLED UNDER 49 CFR PARTS 15 AND 1520. NO PART OF THIS RECORD MAY BE DISCLOSED TO PERSONS WITHOUT A NEED TO KNOW AS DEFINED IN 49 CFR PARTS 15 AND 1520 EXCEPT WITH THE WRITTEN PERMISSION OF THE ADMINISTRATOR OF THE TRANSPORTATION SECURITY ADMINISTRATION OR THE SECRETARY OF TRANSPORTATION* UNAUTHORIZED RELEASE MAY RESULT IN CIVIL PENALTIES OR OTHER ACTION* FOR U*S* GOVERNMENT AGENCIES PUBLIC DISCLOSURE IS GOVERNED BY 5 U*S*C. The form must be completed in its entirety. Once completed this form is not considered Sensitive Security Information* Section 1. Facility and Contact Data Date of physical visit / Name of business visited Also doing business as trade name Business type Employer s Identifying Number Number of years in business Name of individual contacted Title Section 2. Facility and Contact Data Date of physical visit / Name of business visited Also doing business as trade name Business type Employer s Identifying Number Number of years in business Name of individual contacted Title Section 2. Address Information Physical address City State Zip Mailing address if different Section 3. Shipper s Contact Information Physical location phone number Principal contact phone number Emergency phone number Fax number Email address Web address Section 4. Address Information Physical address City State Zip Mailing address if different Section 3. Shipper s Contact Information Physical location phone number Principal contact phone number Emergency phone number Fax number Email address Web address Section 4. Verifier s Information Name title of employee or authorized representative verifying the above information Name of aircraft operator/ foreign air carrier/ or indirect air carrier Phone number I certify the above information is true and correct and the onsite visit and verification was conducted in person as required by the TSA standard security program and applicable security directives.

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