TYPE OF DISCHARGE 26. SERIAL NUMBER 28. IF DISCHARGE WAS OTHER THAN HONORABLE EXPLAIN IN FULL DETAIL U.S. CUSTOMS AND BORDER PROTECTION CBP Form 3078 2/18 If Yes explain details Page 1 of 2 30. DEPARTMENT OF HOMELAND SECURITY U*S* Customs and Border Protection OMB APPROVAL NO. 1651-0008 EXPIRATION DATE 02/28/2018 ESTIMATED BURDEN 17 MIN APPLICATION FOR IDENTIFICATION CARD 19 U*S*C. 66 1551 1555 1565 1624 1641 19 CFR 112. 42 118 122. 182 146. 6 2. DATE OF THIS APPLICATION 1. TYPE OF ACTIVITY REQUIRING IDENTIFICATION CARD Cartman/ Lighterman Broker s Employee CBP Security Area Identification Warehouse Officer Container Station Foreign Trade Zone CES 3. NAME Last First Middle 4. SOCIAL SECURITY NUMBER 5. LIST ANY OTHER NAMES YOU HAVE EVER BEEN KNOWN BY Nicknames aliases etc* 6. DATE OF BIRTH 7. HOME ADDRESS Number Street City State and ZIP Code 8. NAME AND ADDRESS OF PRESENT EMPLOYER 9. HOME PHONE NUMBER 10. BUSINESS PHONE NUMBER 11. PLACE OF BIRTH City County State and Country 12. HEIGHT 13. WEIGHT 14. COLOR HAIR 15. COLOR EYES 16. VISIBLE SCARS OR MARKS 17. U*S* COAST GUARD PORT SECURITY CARD NUMBER 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 DENIED YES Skip Items 20 and 21 NO If Yes explain in Item 21 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 Number and Street To City State PRESENT 23. HAVE YOU EVER SERVED IN THE ARMED SERVICES OF THE U*S* 24. BRANCH OF SERVICE Skip Items 24-28 25. DATES OF SERVICE 27. PREVIOUS EMPLOYMENT -- LIST IN CHRONOLOGICAL ORDER GIVING EARLIEST EMPLOYMENT FIRST Last 10 Years EMPLOYER NAME AND ADDRESS OCCUPATION may exclude any items which occurred before your 16th birthday IN THIS COUNTRY OR ELSEWHERE YES If YES explain in Item 32. Date Place Charge 33. DO YOU NOW USE OR HAVE YOU EVER USED NARCOTIC DRUGS 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. Final Disposition Court below. NO 34. ATTACH PHOTOGRAPH HERE SIGNATURE Sign in ink 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 5 U*S*C. 552a e 3 this Privacy Act Statement serves to inform you of why DHS is requesting the information on this form* CBP is authorized to collect requesting this information 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.
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