Maritime Identification Credentials -- Title 33 CFR Part 125

Enter personnel security data in the grey cells. Invalid data entries will be highlighted red.

Please do not enter slashes, dashes, hyphens or any other special characters.

Name of the facility submitting employee information. Facility name should match the name under which MSTA security plan was submitted. FACILITY/ORGANIZATION NAME

Name of the person to contact about any errors or problems with this submission. NAME OF PREPARER

Primary phone number at which the preparer may be contacted if there are any questions concerning this submission, including area code and extension (if applicable) PREPARER PHONE NUMBER

The full last name (surname) or names of the employee and any suffix (Jr. , Sr. , III, etc.) if applicable. If more than one last name is used (such as paternal and maternal surnames or hyphenated names) include all last names used. Required for each employee. LAST NAME

The full given name for the employee. Do not use nick name or alias. Required for each employee. FIRST NAME

The full middle name for the employee (if applicable). MIDDLE NAME

The date of birth for the employee in numerals. Please do not enter slashes, hyphens or other characters. Where MM = number of month in year, DD = number of day in month, and YYYY = year. Required for each employee. DATE OF BIRTH (MMDDYYYY)

Social Security Number assigned to employee by the U.S. Social Security Administration, if applicable. Enter numbers only, Please do not enter hyphens. SOCIAL SECURITY NUMBER (no dashes or hyphens)

Alien Identification Number assigned to employee, if applicable. ALIEN IDENTIFICATION NUMBER