Appendix F All data in this PRD report is current as of 12/30/2021
FOR CURRENT AND / OR PREVIOUS EMPLOYERS Chief Pilot Air Carrier 121 101 Airport Freeway Big City, IX 00000 United States
PILOT CONSENT FOR THE RELEASE OF RECORDS L,J , consent to and authorize release of records pertaining to me as required under 49 USC 44703(h).
Certificate Number: 000000000 Electronic Signature:
Date: 12/01/2020 Mailing Address: 100 Main Street, Anyplace OK 00001 Page 2 of 13 000000000 Printed on 12/30/2021 12:37:50 PM The data contained in this PRD record must be used solely for hiring decisions and must not be copied or distributed except in accordance with Public Law 111-216 F-2
Appendix F All data in this PRD report is current as of 12/30/2021 In accordance with 49 USC 44703(h), the Airline Safety and Federal Aviation Administration Extension Act of 2010, this PRD record may be used solely for hiring decisions. This PRD record presents verification of a pilot's airman and medical protected from unintended disclosure.
Confidentiality Warning:
This record and any attachments contain confidential and privileged information. If the reader is not the intended recipient, employee, or agent responsible for delivering it to the intended recipient, you are notified that any unauthorized dissemination, publication, copying, or other use of this communication (whether intentional or otherwise) is strictly prohibited and may be illegal.
Notices:
•The following record data was derived from official FAA authoritative data systems.
*This report may include unsatisfactory practical tests, accidents and/or incidents, and/or enforcement reports dated August 1, 2010 and later associated with the current pilot certificate number. Records dated prior to August 2010 may be available via FAA Form AC 8060-72 and the Privacy Act.
• This report will not include open or pending legal action details as they are not releasable until the case is closed.
• Recent applications for an airman certificate, added rating and/or authorization that resulted in the issuance of a temporary certificate issued 120 days or less preceding the date of this report may not have been processed by the Civil Aviation Registry and, consequently, may not appear on the enclosed airman's verification of certificates and/or ratings.
• With regard to administrative actions that may have been issued to the airman named in this PRD record, we will neither confirm nor deny whether such administrative actions exist under exemption 3, which incorporates various nondisclosure provisions that are contained in other federal statutes. In this case, the applicable statute is 49 U.S.C. Section 40123, which provides that certain voluntarily provided safety and security information is protected from disclosure to encourage persons to provide the information to the Federal Aviation Administration (FAA). If the Administrator issues an order designating information as protected under 49 U.S.C. 40123, that information will not be disclosed under the Freedom of Information Act (Title 5 of the United States Code (5 U.S.C.), section 552) or other laws, except as provided in 49 U.S.C 40123, 14 CFR part 193, and the order designating the information as protected. The Administrator has issued FAA Order 8000.82 designating certain information from an Aviation Safety Action Program as protected from disclosure under 49 U.S.C. 40123.
Page 3 of 13 000000000 Printed on 12/30/2021 12:37:50 PM The data contained in this PRD record must be used solely for hiring decisions and must not be copied or distributed except in accordance with Public Law 111-216 F-3
Appendix F All data in this PRD report is current as of 12/30/2021
FAA DATA
PILOT INFORMATION Name:
Permanent Address: 100 MAIN STREET, ANYPLACE OK 00001
AIRLINE TRANSPORT PILOT Cert. No.: 000000000 DOI: 06/02/2017 AAMEL (Airplane Multiengine Land) BAE-146 AVRO RJ C/ASEL (Airplane Single Engine Land) Limitations:
ENGLISH PROFICIENT.
FLIGHT INSTRUCTOR Cert. No: 000000000 DOI: 03/10/2017 F/ASE (Airplane Single Engine) ** Suspended ** Limitations:
VALID ONLY WHEN ACCOMPANIED BY PILOT CERTIFICATE NO. 00000000. EXPIRES: 01 OCT 2018.
MEDICAL CERTIFICATE Medical Class: First Medical Date: 12/14/2020 Limitations:
MUST WEAR CORRECTIVE LENSES.
Page 4 of 13
- 000000000 Printed on 12/30/2021 12:37:50 PM The data contained in this PRD record must be used solely for hiring decisions and must not be copied or distributed except in accordance with Public Law 111-216.
F-4
Appendix F All data in this PRD report is current as of 12/30/2021
NOTICES OF DISAPPROVAL A search of the FAA Comprehensive Airman Information System (CAIS) on the date of this report, revealed the following failed practical tests on file for this pilot.
Name Cert Nbr. Disapproval Disapproval Rate Disapproval Type Rating Date 000000000 9/30/2016 AMES Airplane Multiengine Sea
DRUG AND ALCOHOL A search of the Pilot Records Database (PRD) on the date of this report, revealed the following drug and alcohol records on file for this pilot.
Agency Non-FAA Mode / Test or Test Type Result Description Company Name Occurrence Date Other DOT PHMSA / 11/01/2019 Pre- Refusal to Record of a pre-employment employment submit to alcohol test conducted under 14 Big Rig Oil Company alcohol test CFR § 120.217(a) and confirmed 101 Drill Bit Avenue with a breath alcohol concentration Oilfield, TX of 0.04 or greater.
(555) 555-1212
ENFORCEMENTS A search of the FAA Enforcement Information System, on the date of this report, revealed the following enforcement records on file for the certificates listed.
Violation Date EIR Number Name Cert. Nbr. Cert. Type.
03/17/2017 00000000 ATP Enforcement Details:
Certificate: 000000000 Final Action Date: 09/03/2018 Final Action Final Sanction Final Sanction Amount Certificate Affected CERT SUSPEND DAYS 30 ATP
ACCIDENTS A search of the FAA Accidents and Incidents on the date of this report revealed the following accidents on file for the certificates listed. For further details, search the NTSB accident database: http://www ntsb.gov/ layouts/ntsb.aviation/index.aspx Accident NTSB ID Name Cert. Cert. Nbr. Position N Make Model Serial Date Type Number 3/17/2017 000000000 Pilot in ACME K-5 K-000 Command (PIC) Page 5 of 13 000000000 Printed on 12/30/2021 12:37:50 PM The data contained in this PRD record must be used solely for hiring decisions and must not be copied or distributed except in accordance with Public Law 111-216.
F-5
Appendix F All data in this PRD report is current as of 12/30/2021
INCIDENTS A search of the FAA Accident and Incident Data System (AIDS), on the date of this report, revealed no incidents.
*** Search reveals no records on file *** RAFT
• 000000000 Printed on 12/30/2021 12:37:50 PM The data contained in this PRD record must be used solely for hiring decisions and must not be copied or distributed except in accordance with Public Law 111-216.
F-6
Appendix F All data in this PRD report is current as of 12/30/2021
PILOT ENTERED EXPERIENCE The following list of current and/or previous employers has been provided directly by the pilot. The Federal Aviation Administration has not, nor has any other entity, verified the information provided. It is the reviewing entity's responsibility to verify that the list of current and previous employers is complete and accurate.
CURRENT EMPLOYER(S) Employer Contact Title Address Phone Email AIR CARRIER CHIEF PILOT 100 AIRPORT (555) 555-1212 •.tst 121 FREEWAY
BIG CITY, IX 00000
PREVIOUS EMPLOYER(S) Employer Contact Title Address Phone Email AIR TOUR CEO 1 DESERT (555) 555-1213
OPERATOR ROAD
ONE MYTOWN, AZ 00001 Page 7 of 13
- 000000000 Printed on 12/30/2021 12:37:50 PM The data contained in this PRD record must be used solely for hiring decisions and must not be copied or distributed except in accordance with Public Law 111-216.
F-7
Appendix F All data in this PRD report is current as of 12/30/2021 In accordance with 49 USC 44703(h), the Airline Safety and Federal Aviation Administration Extension Act of 2010, this PRD record may be used solely for hiring decisions. This PRD record presents industry records of employment, disciplinary actions (if any), drug or alcohol incidents (if any) and training. This PRD record contains personally sensitive information and must be protected from unintended disclosure.
The following records have been provided by Reporting Entities in compliance with Public Law 111-216.
AIR CARRIER EXPERIENCE A search of the Reporting Entity data in PRD on the date of this report, revealed the following Employer records on file for the certificates listed.
CURRENT EMPLOYER(S) D Employer Date of Hire Separation Separation Type Records No Additional Status Date Complete Date Records Date 000000000- AIR 01/02/2017 11/01/2021 12/30/2021 E0005 CARRIER 121 (AC121) *Disputed Pending - Pending inaccuracy request to modify record.
PREVIOUS EMPLOYER(S) Employer Date of Hire Separation Separation Type Records No Additional Status Date Complete Date Records Date 000000000- 135 1/9/2017 03/21/2017 Termination - 07/30/2021 07/30/2021 * E0004 CARRIER pilot pertormance (135AC) 000000000- 125 AIR 1/20/2016 01/08/2017 Subsumed by 135 E0003 LLC CARRIER (125LLC) (135AC) 000000000- AIR TOUR 01/4/2015 12/30/2015 Other - details 06/01/2021 06/01/2021 E0002 OPERATOR ONE (ATO01) 000000000- AIR TOUR Comments Defunct: Ceased operations 12/30/2015 E0001 OPERATOR ONE (ATO01) * - Disputed record.
Pending - Pending inaccuracy request to modify record.
EXPERIENCE - DISCIPLINARY ACTION A search of the Reporting Entity data in PRD on the date of this report, revealed the following disciplinary actions on file for the certificates listed.
Record ID Reporting Entity Date of Action Type Removal from Disputed /(Designator Code) Action Operations 000000000- 135 CARRIER (135AC) 03/21/2017 Termination Yes * DA0001 * - Disputed record.
Pending - Pending inaccuracy request to modify record Page 8 of 13 000000000 Printed on 12/30/2021 12:37:50 PM The data contained in this PRD record must be used solely for hiring decisions and must not be copied or distributed except in accordance with Public Law 111-216.
F-8
Appendix F All data in this PRD report is current as of 12/30/2021
EXPERIENCE - DUTIES HISTORY A search of the Reporting Entity data in PRD on the date of this report, revealed the following duties history on file for the certificates listed.
Record ID Reporting Entity Duty Duty Position Make / Model Duty Position Status /(Designator Code) Position (FAA Order Release Date Start Date 8900.1) 00000000- AIR CARRIER 121 01/15/2019 Pilot-in- AVRO RJ DH0006 (AC121) command 00000000- AIR CARRIER 121 09/15/2017 Second-in- AVRO RJ DH0005 (AC121) command 00000000- AIR CARRIER 121 05/02/2017 Second-in- BAE-146 DH0004 (AC121) command 00000000- 135 CARRIER 01/09/2017 Second-in- BAE-146 03/21/2017 DH0003 (135AC) command 00000000- 125 AIR LLC 01/20/2016 Second-in- BAE-146 01/08/2017 DH0002 (125LLC) command 00000000- AIR TOUR 01/04/2015 Second-in- BAE-146 FK-28 12/30/2015 DH0001 OPERATOR ONE command (ATO01) * - Disputed record.
Pending - Pending inaccuracy request to modify record.
EXPERIENCE - DRUG AND ALCOHOL A search of the Reporting Entity data in PRD on the date of this report, revealed the following drug and alcohol records on file for the certificates listed.
Record ID Employer® Test or Test Type Result Description Status Occurrence Date 000000000- 135 CARRIER 03/17/2017 Alcohol Pre-duty use Record of pre-duty Pending DA0001 (135AC) Misuse alcohol use, as defined under 14 CFR § 120.37(d).
* - Disputed record.
Pending - Pending inaccuracy request to modify record.
Page 9 of 13
- 000000000 Printed on 12/30/2021 12:37:50 PM The data contained in this PRD record must be used solely for hiring decisions and must not be copied or distributed except in accordance with Public Law 111-216.
F-9
Appendix F All data in this PRD report is current as of 12/30/2021
EXPERIENCE - TRAINING, QUALIFICATION OR PROFICIENCY RECORDS A search of the Reporting Entity data in PRD on the date of this report, revealed the following training, qualification records on file for the certificates listed.
Record Employer® Start Date End Date Aircraft Duty Program Event Results Status Make / Position Model 00000000- AIR 12/15/2020 12/2020 AVRO PIC Other Sat TPQ0036 CARRIER RJ 121 (AC121 00000000- AIR Comment Vaccine transportation.
TPQ0036 CARRIER 121 (AC121 00000000- AIR 07/16/2020 07/0/2020 AVRO PIC 121 Secondary Sat TPQ0035 CARRIER RJ Subpart Curriculum - 121 (AC121 Y Refresher 00000000- AIR 07/15/2019 07/15/2019 AVRO PIC 121 Secondary Sat TPQ0034 CARRIER RJ Subpart Curriculum - 121 (AC121 Y Requalification 00000000- AIR 01/25/2019 01/27/2019 AVRO PIC 121 Secondary Sat TPQ0033 CARRIER RJ Subpart Curriculum - 121 (AC121 Y Upgrade 00000000- AIR 01/20/2019 01/22/2019 AVRO PIC 121 Secondary Sat TPQ0032 CARRIER RJ Subpart Curriculum - 121 (AC121 Y Conversion 00000000- AIR 01/15/2019 01/17/2019 AVRO PIC 121 Secondary Sat TPQ0031 CARRIER RJ Subpart Curriculum - 121 (AC121 Y Transition 00000000- AIR 01/03/2019 01/08/2019 AVRO PIC 121 Continuing Sat TPQ0030 CARRIER RJ Subpart Qualification 121 (AC121 Y Curriculum - Special Tracking 00000000- AIR 12/01/2018 12/01/2018 AVRO SIC 121 Continuing Sat TPQ0029 CARRIER RJ Subpart Qualification 121 (AC121 Y Curriculum - Line Check 00000000- AIR 07/15/2018 07/15/2018 AVRO SIC 121 Continuing Sat TPQ0028 CARRIER RJ Subpart Qualification 121 Curriculum - (AC121) Line Operational Evaluation 00000000- AIR 01/05/2018 01/05/2018 AVRO SIC 121 Continuing Sat TPQ0027 CARRIER RJ Subpart Qualification 121 Curriculum - (AC121) Maneuvers Validation 00000000- AIR 12/02/2017 12/07/2017 AVRO SIC 121 Continuing Sat TPQ0026 CARRIER RJ Subpart Qualification 121 Y Curriculum - (AC121) Special Qualification Training Page 10 of 13 The data contained in this PRD record must be used solely for hiring decisions and must not be copied or distributed except in accordance with Public Law 111-216. - 000000000 Printed on 12/30/2021 12:37:50 PM F-10
Appendix F All data in this PRD report is current as of 12/30/2021 Record Employer Start Date End Date Aircraft Duty Program Event Results Status Make / Position Model 00000000- AIR 09/30/2017 09/30/2017 BAE- SIC 121 Continuing Sat TPQ0025 CARRIER 146 Subpart Qualification 121 Y Curriculum (AC121) 00000000- AIR 09/15/2017 09/20/2017 AVRO SIC 121 Qualification Sat TPQ0024 CARRIER RJ Subpart Curriculum - 121 Y Special (AC121) Tracking 00000000- AIR 08/30/2017 08/30/2017 BAE- SIC 121 Qualification Sat TPQ0023 CARRIER 146 Subpart Curriculum - 121 Y Operating (AC121) Experience Qualification Curriculum - Line Check 00000000- AIR 08/15/2017 08/15/2017 BAE- SIC 121 Qualification Sat TPQ0022 CARRIER 146 Subpart Curriculum - 121 Y Line (AC121) Operational Evaluation 00000000- AIR 08/01/2017 08/02/2017 BAE- SIC 121 Qualitication Sat TPQ0021 CARRIER 146 Subpart Curriculum - 121 Y Maneuvers (AC121) Validation 00000000- AIR 07/15/2017 07/15/2017 BAE- SIC 121 Qualification Sat TPQ0020 CARRIER 146 Subpart Curriculum - 121 Y Systems (AC121) Knowledge Validation 00000000- AIR 06/01/2017 06/03/2017 BAE- SIC 121 Qualification Sat TPQ0019 CARRIER 146 Subpart Curriculum - 121 Special (AC121) Qualification Training 00000000- AIR 05/15/2017 05/20/2017 BAE- SIC 121 Qualitication Sat TPQ0018 CARRIER 146 Subpart Curriculum 121 Y (AC121) 00000000- AIR 05/05/2017 05/08/2017 BAE- SIC 121 Indoctrination Sat TPQ0017 CARRIER 146 Subpart Curriculum 121 Y (AC121) 00000000- 135 01/30/2017 01/30/2017 BAE- SIC 135 Recurrent Sat Pending TPQ0016 CARRIER 146 Competency (135AC) Check 00000000- 135 01/20/2017 01/20/2017 BAE- SIC 135 Recurrent Sat Pending TPQ0015 CARRIER 146 Knowledge (135AC) Test;
Written/Oral 00000000- 135 01/15/2017 01/15/2017 BAE- SIC 135 Initial Sat Pending TPQ0015 CARRIER 146 Competency (135AC) Check Page 11 of 13 000000000 Printed on 12/30/2021 12:37:50 PM The data contained in this PRD record must be used solely for hiring decisions and must not be copied or distributed except in accordance with Public Law 111-216.
F-11
Appendix F All data in this PRD report is current as of 12/30/2021 Record Employer Start Date End Date Aircraft Duty Program Event Results Status Make / Position Model 00000000- 135 01/11/2017 01/11/2017 BAE- SIC 135 Initial Sat * TPQ0014 CARRIER 146 Knowledge (135AC) Test;
Written/Oral 00000000- 125 AIR 10/01/2016 10/01/2016 BAE- SIC 125 Other Sat TPQ0013 LLC 146 (125LLC) 00000000- Comments Hazard Material Training TPQ0013 00000000- 125 AIR 08/01/2016 08/01/2016 BAE- SIC 125 Recurrent Sat TPQ0012 LLC 146 Knowledge (125LLC) Test;
Written/Oral 00000000- 125 AIR 02/09/2016 02/09/2016 BAE- SIC 125 Instrument Sat TPQ0011 LLC 146 Proficiency (125LLC) Check 00000000- 125 AIR 02/07/2016 02/08/2016 BAE- SIC 125 Initial Sat TPQ0010 LLC 146 Competency (125LLC) Check 00000000- 125 AIR 02/05/2016 02/05/2016 BAE- SIC 125 Initial Sat TPQ0009 LIC 146 Knowledge (125LLC) Test;
Written/Oral 00000000- 125 AIR 01/30/2016 02/02/2016 BAE- SIC 125 Initial Unsat Pending TPQ0008 LLC 146 Knowledge (125LLC) Test;
Written/Oral 00000000- Comments Unfamiliar with EFVS operations.
TPQ0008 00000000- AIR TOUR 12/01/2015 12/02/2015 BAE- SIC PAC Other Sat TPQ0007 OPERATOR 146 ONE (ATO01) 00000000- Comments Hazard Material Training TPQ0007 00000000- AIR TOUR 11/01/2015 11/02/2015 BAE- SIC PAC Recurrent Sat TPQ0006 OPERATOR 146 Training ONE (ATO01) 00000000- AIR TOUR 08/01/2015 08/01/2015 BAE- SIC PAC Instrument Sat TPQ0005 OPERATOR 146 Proficiency ONE Check (ATO01) 00000000- AIR TOUR 07/15/2015 07/18/2015 BAE- SIC PAC Initial Training Sat TPQ0004 OPERATOR 146 ONE (ATO01) 00000000- AIR TOUR 06/20/2015 06/23/2015 FK-28 SIC PAC Recurrent Sat TPQ0003 OPERATOR Training ONE (ATO01) Page 12 of 13 The data contained in this PRD record must be used solely for hiring decisions and must not be copied or distributed except in accordance with Public Law 11-216. Printed on 12/30/2021 12:37:50 PM F-12
Appendix F All data in this PRD report is current as of 12/30/2021 Record Employer Start Date End Date Aircraft Duty Program Event Results Status Make / Position Model 00000000- AIR TOUR 01/30/2015 01/30/2015 FK-28 SIC PAC Instrument Sat TPQ0002 OPERATOR Proficiency ONE Check (ATO01) 00000000- AIR TOUR 01/15/2015 01/18/2015 FK-28 SIC PAC Initial Training Sat TPQ0001 OPERATOR ONE * - Disputed record. (ATO01) RAFT Pending - Pending inaccuracy request to modify record.
Page 13 of 13
- 000000000 Printed on 12/30/2021 12:37:50 PM The data contained in this PRD record must be used solely for hiring decisions and must not be copied or distributed except in accordance with Public Law 111-216.
F-13