Access Control Form

Access Control Application

This form is to be used when applying for Access Control Permissions at Darwin International Airport for New or Renewed ASICs and Access Cards. If the valid ASIC is proxy (eg: can be coded directly) or you have a current DIA issued Access Card, this will be programmed at no cost. If the ASIC is non-proxy (cannot be coded) then a separate Access Card will be provided at a charge of $20.00 inc GST.

PART 1 - TO BE COMPLETED BY APPLICANT

SECTION A - APPLICANT DETAILS

First Name/s *

Last Name *

Email *

Employed By *

Position *

ASIC Number *

ASIC Expiry Date *

ASIC Designation *

DRWAUS

ASIC Color *

RedGrey

ASIC Upload *

Browse

Accepted format: jpg, png, jpeg, pdf

Note: A photo of your current ASIC must be attached to this application form

Date of Birth *

Gender

MaleFemaleOtherRather Not Disclose

Address *

Street address *

City *

State *

Postcode *

Email Address *

Contact Telephone Number *

To check who the Authorising Signatories are for the purpose of Access and Security Control, and avoid any application processing delays, please contact the Terminal Control Centre, Gate A, ground floor | call 08 8920 1822 or email tcc.reception@adgnt.com.au. Applications signed by anyone other than an approved Authorising Signatory will be returned.

Company Signatory Name *

Company Signatory Email *

SECTION B - APPLICANT CERTIFICATION

I, (Applicant Name) *

Hereby:

(i) confirm that that I have read and understood the conditions of issue and use for all DIA Access Control and Access Cards and agree to comply with these conditions;

(ii) acknowledge that I have read, understood and accept the DIA Privacy Statement attached to this application form;(iii) certify that the details contained in this application are true and correct and understand I must contact DIA immediately if any of the information changes.

Applicant Signature *

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Applicant Signature Date *

PAYMENT OPTIONS

If your ASIC is proxy there will be no payment required to add access control. If your ASIC card cannot be coded to, DIA will supply a proxy Access Card at a cost of $20.00 inc GST. Payment for Access Card Access Control permissions must be made at the time of submission; no application will be accepted without payment. If you have an existing DIA Access Card we will attempt to reprogram this at no cost.

Access Card with new Access Control Permissions Cost: $20.00 inc GST

DIA accepts the following methods of payment:

Cash
EFTPOS
Credit Card
Cheque made payable to Darwin International Airport

Your Company has the option of providing DIA with an Ongoing Credit Card Authority Form that will be securely retained by us and used for payment each time an application is submitted. Alternatively, a Single Payment Credit Card Authority Form can be attached which wewill use for a once off payment. Both of these forms are available on our website www.darwinairport.com.au (Working On Airport)

ACCESS CARDS - PRIVACY STATEMENT AND CONDITIONS OF USE

PRIVACY STATEMENT

Collection and disclosure to third parties of the information contained within this application form is required in order to enable theprocessing of Access Control onto your DIA issued Access Card. The collection and handling of information is in compliance with Division9 - Aviation Transport Security Act 2004, Part 6 - Aviation Transport Security Regulations 2005, AusCheck Regulations 2007, DarwinInternational Airport Transport Security Program and The Privacy Act 1988.

In addition, we may use your personal information for the purposes of assisting DIA with the correct operating of the airport under variouslegislation, and in the assessment of any possible security incidents or breaches. Information may also be supplied to third parties inconjunction with any federal investigations.

By submitting this application, you consent to DIA collecting, using and disclosing personal information as set out above.

ACCESS CARD CONDITIONS OF USE AND ISSUE

• Access on card will expire on the same expiry date as the holders’ current ASIC• Loss of card is to be reported immediately to DIA Terminal Control Centre – (08) 8920 1822

• The Access Card remains the property of DIA and must be surrendered on expiry, transfer or termination of present duty, or on requestby DIA

• The card may only be used in the course of the cardholder’s approved duties in the Secure Areas and does not constitute an authority toenter or remain in a restricted area for any other purpose

• Access on cards is registered for the use of the person to whom it has been issued only

• Incorrect use of access provisions may result in the immediate withdrawal of access privileges. No refund will be granted

• If you have a separate DIA Access Card with Access Control permissions, then these permissions will expire on the same date that yourASIC expires

• DIA will attempt to reprogram an existing Access Control Card, should the card be deemed damaged or invalid a new Access Control Cardwill be issued at a cost of $20 in GST

SECURITY AND SAFETY INDUCTION

Before you can have your ASIC or Access Card programmed with access control privileges you must complete the Darwin InternationalAirport Security Induction and NT Working on Airport Induction; this is a mandatory requirement with the objective of keeping DarwinInternational Airport safe and secure.

If you require access to either, or both of, the Fixed Aerobridge and Apron Drive Aerobridge you must complete the Induction for eachtype of aerobridge.

The induction is based online and consists of multiple choice questions; all questions have been captured from the Airport Security andSafety Awareness Guide, copies of which are available to download from our website at Access control | Darwin International Airport (darwinairport.com.au)(Working on Airport). Please visit our website and register to sit the induction. Once you have registered, you will receive an email withyour username and password and a link to the induction. On successful completion of the induction you will receive an additional emailwith an attached Training Record; you are required to print and sign the Training Record and bring it with you to the Terminal ControlCentre (Gate A) along with your application form.

I confirm that I have read and understood the Access Card Privacy Statement and Conditions of Use Confirmation, and agree to adhear to all requirements as outlined above by Darwin International Airport. *

I understand that failure to comply with the Access Card Condition of Use outlined above will result in my access permissions being revoked at the discretion of Darwin International Airport. *

PART 2 - TO BE COMPLETED BY EMPLOYER (AUTHORISED SIGNATORY ONLY)

SECTION B - Employer Details

Company Name *

Company Authorised Signature Name *

Preferred Phone Contact Type *

Work Phone Number

Mobile Phone Number

Employer Email Address *

Employer Postal Address *

Street address or PO Box *

City *

State *

Postcode *

SECTION B - Access Requirements

Access Areas Required *

Aerobridge Access: Employee will be registered to complete the Online Aerobridge Induction

N/AApron Drive Aerobridge (Bay 1 & 5)Fixed Aerobridge (Bay 2 - 4)All Aerobridges (Drive & Fixed)

Aerobridge Training Log Upload *

Browse

Reason for Access: (You must be specific – justify the applicant’s need to access secure areas by stating actions and duties involved in position) *

EMPLOYER PAYMENT CONFIRMATION

In the event that your employees ASIC card cannot be coded to, DIA will supply a proxyAccess Card at a cost of $20.00 inc GST. Payment for Access Card Access Control permissions must be made at the time of submission; noapplication will be accepted without payment. If the employee has an existing DIA Access Card we will attempt to reprogram this at no cost

Access Card with new Access Control Permissions Cost: $20.00 inc GST

Please select from one of the below in the event that ASIC cannot be coded, and employee does not hold an existing DIA access card:

Is an Access Card Required?

YesNo - ASIC can be coded

Access Card Payment *

Company to PayEmployee to Pay

*Please ensure correct cash is presented to TCC prior to collection of Access Card by employee

*Payment can be made by presenting to TCC office, or over the phone by contacting (08) 8920 1822.

*For all Cheque payments, please contact TCC office on (08) 8920 1822.

*If you are unsure if monthly account payments have been set up for your company, please contact TCC office on (08) 8920 1822.

NA Reason *

SECTION C - Employer Certification

I, (Authrorised Company Signatory Name) *

(i) confirm that the preceding applicant and employer details are correct and that the applicant requires access to the SecuritySensitive Areas at DIA in order to perform their duties for their employment;

(ii) agree to notify DIA of any changes to the above and to recover and return any DIA issued Access Card prior to the applicantleaving your employment or upon transfer to a position which no longer has an operational need to retain the Access Card;

(iii) understand that DIA may exercise its right to suspend production of Access Cards for any company who has expired/unrecovered Access Cards that have not been returned to DIA;

I declare that i am listed as an Authorised Company Signatory. *

Employer Signature *

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Employer Signature Date *

SECURITY CONFIRMATION AND APPROVAL.

Is Authorised Company Signatory Valid? (Check SDS) *

YesNo

Declined Reason

Is access requested within operational requirements? *

YesNo

Company Name *

Authorised Company Signatory Email/s (Separate emails using ", ") *

Security Induction Completed *

Aerobridge Induction/s Completed (If Applicable)

PACOM Updated *

Security Staff Name *

CAPTCHA *

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