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APPLICATION FOR/RENEWAL OF A SECURITY THREAT ASSESSMENT (STA)
STA Renewals Only
CURRENT EMPLOYER NAME
CURRENT EMPLOYER CORPORATE ADDRESS
CITY
STATE
ZIP
EMPLOYER PHONE NUMBER
IAC PRINCIPAL
(REFER TO SECTION 2 FOR DEFINITION)
Yes
No
IAC PRINCIPAL TITLE
(IF IAC PRINCIPAL)
NAME
(FIRST MIDDLE LAST SUFFIX)
SOCIAL SECURITY NUMBER
(OPTIONAL)
PREVIOUS NAME USED
(FIRST MIDDLE LAST SUFFIX) (IF APPLICABLE)
PREVIOUS NAME USED
(FIRST MIDDLE LAST SUFFIX) (IF APPLICABLE)
EMAIL ADDRESS
(OPTIONAL)
DAYTIME PHONE NUMBER
DATE OF BIRTH
(MM/DD/YYYY)
GENDER
MALE
FEMALE
PLACE OF BIRTH
(CITY, STATE, COUNTRY)
COUNTRY OF CITIZENSHIP
US PASSPORT NUMBER OR CERTIFICATE OF BIRTH ABROAD NUMBER
(IF APPLICABLE)
ALIEN REGISTRATION NUMBER
(IF APPLICABLE)
NATURALIZATION DATE
(IF APPLICABLE)
NATURALIZATION CERTIFICATE NUMBER
(IF APPLICABLE)
CURRENT MAILING ADDRESS
CITY
STATE
ZIP
CURRENT RESIDENTIAL ADDRESS
START DATE AT THIS ADDRESS
END DATE AT THIS ADDRESS
CITY
STATE
ZIP
PREVIOUS RESIDENTIAL ADDRESS 1
START DATE AT THIS ADDRESS
END DATE AT THIS ADDRESS
CITY
STATE
ZIP
PREVIOUS RESIDENTIAL ADDRESS 2
START DATE AT THIS ADDRESS
END DATE AT THIS ADDRESS
CITY
STATE
ZIP
PREVIOUS RESIDENTIAL ADDRESS 3
START DATE AT THIS ADDRESS
END DATE AT THIS ADDRESS
CITY
STATE
ZIP
PREVIOUS RESIDENTIAL ADDRESS 4
START DATE AT THIS ADDRESS
END DATE AT THIS ADDRESS
CITY
STATE
ZIP
 
