Print clearly in all fields except for signature. The form must be completed in its entirety. Print form * Required
Date of physical visit : Month Day Year 20
* Name of business visited: (Customer's name)
Also doing business as (trade name):
Name of individual contacted:
Title
Employers Identifying (EIN) Number:
What type of business?
How long in business?
Address information
* Physical Address	Mailing address :(if different from physical)
	Address_______________________________
	_______________________________
* City:	City ____________________________________
* State:	State _______________________________
*Postal code:	Postal code ______________________________
Shippers Contact Information
* Physical location phone number :
Principal contact phone number :
*Emergency phone number :
Facsimile number :
E-mail address :
Web address :
Verifier's information
Name of IAC employee or authorized representative verifying above information :
Title :
Name of Indirect air carrier : TSA approval number: EA9807001
Phone number :
E-mail :
I certify the above information is true and correct and the onsite visit and verification was conducted in person as required by the Meest-America inc. TSA-approved security program and applicable security directives. This certification is (!) made with the understanding that any intentional falsification may be subject to both civil and criminal penalties under 49 CFR 1540. 103 and 18 USC 1001 and )ii) subject to keeping requirements approved by TSA.
Signature of verifier : _____________________________________
* Signature of shipper : ___________________________________
Sensitive Security Information
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 penalty or other action. For U.S. government agencies, public disclosure is governed by 5 U.S.C 552 and 49 CFR parts 15 and 1520.