# U.S. Department of Homeland Security

# Arlington, VA 22202

![](media/image1.png){width="2.25in" height="0.7652777777777777in"}

**Order Form for TSA's:**

-   ***Pipeline Security Awareness for Pipeline Industry Employees* --
    CD**

-   ***Pipeline Security Awareness for Employees* -- Brochure**

-   ***Good Neighbors, A Pipeline Security Neighborhood Watch* --
    Brochure**

**A. Instructions**

Complete the information requested, read the usage agreement below,
click on the "*To Email Your Order Form*" link on the TSA Pipeline
Security web page, and send this document as an email attachment, on the
pre-addressed email,

**OR:** in a separate e-mail, send this document as an attachment to the
following

e-mail address:
[**pipelinesecurityrequest@dhs.gov**](mailto:pipelinesecurityrequest@dhs.gov)

**OR:** if desired, you can mail the completed form to:

Pipeline Security Request

c/o TSA/TSNM Pipeline Security Division

601 S. Twelfth St.

stop TSA-28

Arlington, VA 22202

**B. Requestor's Information**

Complete this part. Information preceded by an \* is required to receive
the CD and/or accompanying material.

\*1. Media material requested: (mark all specific items requested)

Training Course on Compact Discs (one per order)

\[ \] PCD-1 "Pipeline Security Awareness for Pipeline Industry
Employees"

Brochures in PDF format (sent as electronic reproducible versions)

\[ \] PF-1 "Pipeline Security Awareness for Pipeline Employees"

\[ \] PF-1A "Good Neighbors, A Pipeline Security Neighborhood Watch "

\*2. Company name:

\*3. Company Representative

Name:

Title:

Telephone number:

Email address:

Mailing address:

4\. Address where CD is to be mailed (if different than above):
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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\*5. Number of pipeline companies or subsidiary pipeline companies
(individual pipeline

systems) represented: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

6\. Names of individual pipeline companies/pipeline systems represented
by this request:

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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7\. Estimated number of employees intended to receive training:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**C. CD Usage Agreement**

> **By submission of this request I agree to adhere to the following
> usage requirements.**
>
> The Pipeline Security Awareness Compact Disk (PCD-1) is provided by
> The Transportation Security Administration, Pipeline Security Division
> for the purpose of assisting pipeline companies in their effort to
> increase security awareness levels among their employees. As such,
> this CD and its contents may be duplicated, copied or uploaded onto
> each requesting company's website in its entirety or in part as deemed
> appropriate by that individual pipeline company and its subsidiary
> pipeline companies if applicable. The reformatting of, or alterations
> to visual or audio content is also permitted to meet company
> requirements. However, this CD is strictly intended for official use
> by the requesting company or its subsidiary pipeline companies.
> Distribution to outside companies or entities other than to subsidiary
> pipeline companies is prohibited without the expressed approval of
> TSA.
>
> The CD course runs approximately 40 minutes, and is designed so that a
> person undergoing the training can exit and re-enter at any time. The
> course also involves interactive questions meant to emphasize key
> points; however they do not constitute a course exam.
>
> [Included as part of CD menu is two sections titled]{.underline}
> *Knowledge Check (company optional)* and *Course Assessment (company
> optional)* --Selecting either of these sections brings up either a
> pre-loaded Knowledge Check or Course Assessment in word document file
> format. These documents may be used, as is, altered, deleted or
> replaced as desired by your company. For instructions on how to
> perform these modifications, see modification instructions mailed
> along with your CD.