AOA BADGE APPLICATION - INSTRUCTIONS - DO NOT STAPLE THIS PAGE TO APPLICATION
• Section A
o Full Legal Name - enter your current, legal name.
o Previously Used Names - enter any aliases you have used, including maiden names.
o Current Mailing Address - enter your current mailing address, PO boxes are acceptable.
o Country of Birth - enter the country you were born in (e.g. USA).
o Citizenship Country - enter the country that you are currently a legal citizen of.
o Alien Registration Number through Passport Number - enter information if applicable, for questions contact officer.
o For What Purpose Are You Applying for This Badge - select the category that best fits why you are applying for an
AOA badge.
▪ T-Hangar Tenant - select this option if you are NAMED on an active t-hangar lease with the airport
▪ T-Hangar Authorized User - select this option if you are a pilot who uses a t-hangar tenants’ aircraft. The T-
Hangar tenant must sign your application in Section B(2).
▪ Rental/Student Pilot - select this option if you currently rent aircraft from the FBO or are a Student Pilot
operating out of LSE, or use another aircraft but don’t need gate access.
▪ Contractor - select this option if you are a contractor performing work at the LSE airport. You will need to
have your application approved by the Authorized Signatory for your project, usually the prime
contractor’s foreman.
▪ FAA - select this option if you are an FAA employee performing NAVAID work at LSE.
▪ Other Tenant - select this option if you are a tenant or are an employee of a tenant located on the airport
(other than t-hangars) and require access to the AOA. Specify on the given line which tenant you are
with. Your application must be approved by the Authorized Signatory for your organization.
• Section B
o Complete section (1) if you are a corporate tenant, contractor, or FAA. You will be required to have the
Authorized Signatory for your organization sign the space given in this section. If you are unsure of who your
Authorized Signatory is, contact an officer for that information.
o Complete section (2) if you are a t-hangar tenant, t-hangar user, rental pilot, student pilot, or other. You will sign
the space under (2) signifying you need a badge and that you are not authorized to drive on the AOA. If you are
a t-hangar user, a t-hangar tenant must also sign giving you gate access.
• Section C
o (1) This section is a certification that you are not making any misrepresentations on this application.
o (2) This section states that you must report any lost badges or loss of need to have a badge to the airport. Failure
to return badges will result in a substantial fee as per current airport policy.
o (3) This section is your acknowledgment of the airport security procedures. You are further certifying that you will
observe gate closures behind you and will prohibit piggybacking.
• Section D
o This section authorizes the Social Security Administration to release your social security number to the TSA for
verification purposes. While not required, not authorizing this release may result in delays in the processing of your
application.
o Privacy act notice explaining how the information provided in this application is used
BADGE PROCESS
1. Complete this application and return to the La Crosse Regional Airport at:
2850 Airport Road
2. Your AOA badge is $50 (subject to change) payable at the time you apply for the badge. You can make
checks payable to the City of La Crosse Treasurer and mail to the address above.
3. Badge applications take approximately 5 days for approval. Call the Airport at (608) 789-7464 to check on your
status after 5 days.
4. When your application has been approved and you have made an appointment to pick up your badge, bring
in one form of ID from both Columns B and C on Page 5 of this application or one form of ID from Column A.
(Example, a driver’s license and social security card is valid OR a passport by itself is valid) Airport staff will need
to see an ORIGINAL of the documents and will make a copy.
Questions can be sent to [email protected]
IMPORTANT: You have 30 days to pick up your badge from the application date, if you do not pick up your
badge within 30 days you will have to repeat the entire application process and repay the fee.
NOTE: AOA badges are good for 2 year periods with all current badges expiring June of odd numbered years
Upon expiration of your badge you will have to re-complete this form, pay a renewal fee (currently $30), and
have an updated badge issued. Do Not post photos of your issued badge online.
Rev. 04/02/2021
Page 1
NEW AND RENEWAL AOA BADGE APPLICATION
A) THIS SECTION TO BE COMPLETED BY APPLICANT
Legal Last Name
Legal First Name
Legal Middle Name
Previously Used Name (Last, First, Middle)
Previously Used Name (Last, First, Middle)
Current Mailing Address
City
State
Zip
Daytime Phone
Employer Phone
E-Mail Address
Employer
Date of Birth (MM/DD/YYYY)
Citizenship Country
State of Birth
Country of Birth
Race
Gender
Male Female
Alien Registration # (If Applicable)
I-94 Arrival/Departure Number (If Applicable)
Non-Immigrant Visa Number (If Applicable)
Certificate of Birth Abroad # (If Applicable)
Certificate of Naturalization # (If Applicable)
Passport Country (If Applicable)
Passport Number (If Applicable)
Height (Feet/Inches)
Weight (Pounds)
Hair Color
Eye Color
Badge Type
Requested?
AOA AOA
Contractor
Badge Purpose:
T-Hangar Tenant T-Hangar User Contractor FAA
Rental/Student Pilot Other _________________________
Reason For
Application?
New Badge Expired Badge Name Change Replace Lost Badge Replace Stolen Badge
Are you a
pilot?
Yes No
Pilots License Number (If Applicable)
Are you a citizen of the United States OR are you authorized to work by the Government of the United States
OR a commercial driver licensed by Canada or Mexico and admitted to the United States under 8 CFR
214.2(b)(4)(i)(E) to conduct business in the United States?
Yes No
AOA
2850 AIRPORT ROAD
LA CROSSE, WI 54603
(608) 789-7464
Rev. 04/02/2021
Page 2
B) COMPLETE SECTION 1 OR 2 ONLY – DO NOT COMPLETE BOTH – ASK IF UNSURE
1) THIS SECTION TO BE COMPLETED BY CORPORATE TENANTS AND CONTRACTOR SIGNATORY
AUTHORITIES – DO NOT COMPLETE IF YOU ARE A T-HANGAR TENANT OR STUDENT/RENTAL PILOT
Applicants Job Title or Purpose
Authorizing Company
Authorizing Signatory Phone Number
AOA badges are issued only upon approval from your organizations Authorized Signatory. This space must be completed.
I, Authorized Signatory for the above applicant, hereby certify that the above listed applicant needs access to the Air Operations Area
to perform their job duties and shall be added to my signed Authorized Signatory - List of Authorized Badge Holders, I further certify that
I am an Authorized Signatory authorized to approve this applicant and will notify the La Crosse Airport upon termination of applicant’s
privileges. The individual applicant acknowledges their security responsibilities under 49 CFR § 1540.105(a);
by checking the following box I hereby certify the above applicant requires escorting privileges based on operational need.
Name of Signatory Authority (Print)
Signatory Authority Signature Authorizing Badge
Date
2) THIS SECTION TO BE COMPELTED BY T-HANGAR TENANTS OR STUDENT/RENTAL PILOTS ONLY
If, you are an aircraft hangar lessee, student pilot or aircraft rental pilot, you can be your own authorized signatory and can sign for
yourself.
I hereby certify that I require access to the AOA in order to operate an aircraft in the AOA as approved by airport management. I
understand that this authorization does not extend driving privileges to areas beyond my rented area. I shall notify the La Crosse
Airport upon termination of my tenancy and shall return my badge at that time.
If you are not the lessee of the aircraft hangar but you use or require access to the hangar, you must have the aircraft hangar lessee
sign this application below authorizing access privileges. Only t-hangar tenants and t-hangar users with an authorized signature will be
granted access to gates. I hereby certify that the applicant listed in Section A above requires access to my leased hangar. I
understand that I am ultimately responsible for the actions of the above listed individual including all charges related to the non-return
of above individual’s AOA access card. Further, I will notify the La Crosse Airport when the above individual does not require access to
my leased hangar.
Name of Applicant (Print)
Signature of Applicant
Date
T-Hangar # (If Applicable)
Signature of T-Hangar Lessee (If Applicable)
Date (If Applicable)
C) NOTICE TO LA CROSSE AIRPORT AOA BADGE APPLICANT (Sign in Presence of Staff Only)
(1) I hereby certify that the information I have provided on this application is true, complete, and correct to the best of my
knowledge and belief and is provided in good faith. I understand that a knowing and willful false statement on this
application can be punished by fine or imprisonment or both (See section 1001 of Title 18 of the United States Code).
Further, I agree and understand that any misstatements of or material omissions of facts hereon may cause forfeiture of my
privilege to receive an Airport Identification Badge. My point of contact for this information shall be the Airport Security
Coordinator.
(2) I understand that Airport Management may deny my access at any time and upon separation from my employment this
proximity card and ID badge will be returned immediately. I understand that if I should lose my proximity card and/or ID
badge I am obligated to report the loss to airport management immediately so that my cards may be removed from the
system. I also understand that there will be a fee, as per current airport policy, for a replacement proximity card and/or ID
badge.
(3) I understand all my responsibilities as they pertain to the possession of a La Crosse Regional Airport Identification Badge.
I will challenge or report immediately to my supervisor and Airport Management, anyone whom I observe in a restricted area
that does not display the proper Airport Identification Badge.
CAUTION: SIGN IN PHYSICAL PRESENCE OF TRUSTED AGENT
Name of Applicant (Print)
Signature of Applicant
Date
Witness - Name of Trusted Agent
Signature of Trusted Agent
Date
Rev. 04/02/2021
Page 3
D) SOCIAL SECURITY NUMBER AUTHORIZATION
I authorize the Social Security Administration to release my Social Security Number and full name to the Transportation Security
Administration, Enrollment Services and Vetting Programs, Attention: Vetting Programs (TSA-10)/Aviation Worker Program, 6595
Springfield Center Drive, Springfield, VA 20598-6010.
I am the individual to whom the information applies and want this information released to verify that my SSN is correct. I know that if I
make any representation that I know is false to obtain information from Social Security records, I could be punished by a fine or
imprisonment or both.
NOTE: An individual who has a U.S. Social Security Administration issued SSN but fails to provide it to TSA may delay or prevent
completion of the STA and may be denied ID media (badge).
Name of Applicant (Print)
Signature of Applicant
Date of Birth
SSN
TSA PRIVACY ACT STATEMENT
Authority: 6 U.S.C. § 1140, 46 U.S.C. § 70105; 49 U.S.C. §§ 106, 114, 5103a, 40103(b)(3), 40113, 44903, 44935-44936,
44939, and 46105; the Implementing Recommendations of the 9/11 Commission Act of 2007, § 1520 (121 Stat.
444, Public Law 110-53, August 3, 2007); FAA Reauthorization Act of 2018, §1934(c) (132 Stat. 3186, Public Law
115-254, Oct 5, 2018), and Executive Order 9397 (November 22, 1943), as amended.
Purpose: The Department of Homeland Security (DHS) will use the information to conduct a security threat
assessment. If applicable, your fingerprints and associated information will be provided to the Federal Bureau of
Investigation (FBI) for the purpose of comparing your fingerprints to other fingerprints in the FBI’s Next
Generation Identification (NGI) system or its successor systems including civil, criminal, and latent fingerprint
repositories. The FBI may retain your fingerprints and associated information in NGI after the completion of this
application and, while retained, your fingerprints may continue to be compared against other fingerprints
submitted to or retained by NGI. DHS will also transmit your fingerprints for enrollment into US-VISIT Automated
Biometrics Identification System (IDENT). DHS will also maintain a national, centralized revocation database of
individuals who have had airport- or aircraft operator- issued identification media revoked for noncompliance
with aviation security requirements. DHS has established a process to allow an individual whose name is
mistakenly entered into the database to correct the record and have the individual’s name expunged from
the database. If an individual who is listed in the centralized database wishes to pursue expungement due to
mistaken identity, the individual must send an email to TSA at Aviati[email protected].gov.
Routine Uses: In addition to those disclosures generally permitted under 5 U.S.C. § 552a(b) of the Privacy Act, all
or a portion of the records or information contained in this system may be disclosed outside DHS as a routine
use pursuant to 5 U.S.C. § 552a(b)(3) including with third parties during the course of a security threat
assessment, employment investigation, or adjudication of a waiver or appeal request to the extent necessary
to obtain information pertinent to the assessment, investigation, or adjudication of your application or in
accordance with the routine uses identified in the TSA system of records notice (SORN) DHS/TSA 002,
Transportation Security Threat Assessment System. For as long as your fingerprints and associated information
are retained in NGI, your information may be disclosed pursuant to your consent or without your consent as
permitted by the Privacy Act of 1974 and all applicable Routine Uses as may be published at any time in the
Federal Register, including the Routine Uses for the NGI system and the FBI’s Blanket Routine Uses.
Disclosure: Pursuant to § 1934(c) of the FAA Reauthorization Act of 2018, TSA is required to collect your SSN on
applications for Secure Identification Display Area (SIDA) credentials. For SIDA applications, failure to provide
this information will result in denial of a credential. For other aviation credentials, although furnishing your SSN is
voluntary, if you do not provide the information requested, DHS may be unable to complete your security
threat assessment.
I have read and understand this Privacy Act Notice:
Printed Name:
Signature: Date:
Rev. 04/02/2021
Page 4
E) THIS SECTION TO BE COMPLETED BY AIRPORT PERSONNEL
Application Process Completed
Trusted Agent Initials
Date
Applicants information completed and correct to best of knowledge
Signatory/Self Authority information completed, signed, and verified
Signatures in Section C completed in presence of Trusted Agent
Application fee paid and payment
submitted to airport administration
office:
Amount $________
Cash
Check #__________
Bill Account________________
New application $50.00
Renewal application $30.00
Lost/Stolen badge application (circle fee)
$30 $100 $150
CAP Cadet/Volunteer $5.00
Verification of identity and work authorization forms and a COPY of each form used
has been attached to application (Highlight Forms Used Below)
Applicants information entered and submitted to TELOS
STA Status
Accepted Rejected
Access/Rules/Regulations training completed
Badge
Issued
AOA (Yellow Background)
AOA Contractor (Blue Background)
Access
Level
Applicant added to signatory master list (if applicable)
Application reviewed and filed by supervisor
Notes
F) LIST OF ACCEPTABLE DOCUMENTS – ALL DOCUMENTS MUST BE UNEXPIRED
Badge
Number: _
_____________
_ File: _
__________________
Applicant
Name: _
____________________________________
Date Issued____________
_ Expiration
Date ______________
TA Terminating ________________
Date Terminated _____________
