Appendix 3 APPENDIX 3. OVERVIEW OF FAA FORM 8060-10A, AIRMAN NOTICE AND RIGHT
TO RECEIVE COPY -- FAA RECORDS (PRIA)
Pilot Records Improvement Act Of 1996, As Amended
NOTICE: Request will not be deemed recei ved or valid unless Parts I and II are completed as specified in the instructions for the form.
1. Part I – Airman Notice And Right To Receive Copy -- FAA Records (PRIA).
a. Part I is used by the FAA to notify the pilot of an FAA Records Request (PRIA) and of the pilot’s right to receive a copy of the records furnished to the requesting air carrier.
b. The FAA will provide records reflecting current airman medical certificate, current airman certificates and associated type ratings, including any limitations to those certificates and ratings. The FAA will also conduct a search of the Enforcement Information System and provide a summary of legal enforcement actions resulting in a finding by the Administrator of a violation of Title 49 U.S.C. or a regulation prescribed or order issued under this Title that has not been subsequently overturned (as provided in 49 U.S.C. § 44703(h)(1)(A)(ii)).
2. Part II – Airman Request Or Non-Request For Records. Part II is used by the pilot to notify the FAA whether or not he/she wants a copy of the records that were furnished to the requesting air carrier.
3. Furnishing Records. A person who receives a request for records under 49 U.S.C.
§ 44703(h) shall provide to the individual who is the subject of the records:
a. On or before the 20th day following the date of receipt of the request, written notice of the request and of the individual’s right to receive a copy of such records, and
b. Furnish a copy of all such requested records not later than 30 days after receiving the request.
4. Reasonable Charges. 49 U.S.C. § 44703(h)(7) allows for reasonable charges for processing requests and furnishing copies of requested records (see paragraph 8g above for further clarification).
Appendix 3
FIGURE 1. FAA FORM 8060-10A, AIRMAN NOTICE AND RIGHT TO RECEIVE COPY -- FAA
RECORDS (PRIA) (FRONT)
AIRMAN NOTICE AND RIGHT TO RECEIVE COPY -- FAA RECORDS (PRIA)
Pilot Records Improvement Act Of 1996 Title 49 U.S.C. § 44703(h), Records of Employment of Pilot Applicants, As Amended
NOTICE
Title 49 U.S.C. § 44703(h)(6) requires the person receiving a records request to notify the individual who is the subject of the request within 20 days after receiving the request, and further entitles the individual the right to receive a complete copy of all FAA records furnished in response to the request within 30-days after receiving the request.
Title 49 U.S.C. § 44703(h)(7) allows for a reasonable ch arge for the cost of pr ocessing the request and furnishing copies of the requested records.
PART I: AIRMAN NOTICE AND RIGHT TO RECEIVE COPY
(Airman Name – First, Middle, Last) (Airman Certificate #) Pursuant to 49 U.S.C. § 44703(h)(6), you are hereby notified that , (Air Carrier Name) , submitted an FAA Records Request (PRIA) dated , (Air Carrier Certificate #) (Date of Request) for your records concerning: (i) current airman medical cer tificate, current airman certificates and associated type ratings, including any limitations to those certificates and ratings, and (ii) summaries of legal enforcement actions resulting in a finding by the Administrator of a violation of Title 49 U.S.C. or a regulation prescribed or order issued under this Title that was not subsequently overturned (as provided by 49 U.S.C. § 44703(h)(1)(A)).
You are hereby notified of your right to receive a copy of any and all records furnished by the Federal Aviation Administration in response to the aforementioned records re quest, and that you may request a copy of such records by checking yes, signing, and dating in Part II below.
PART II: AIRMAN REQUEST OR NON-REQUEST FOR RECORDS YES, I want a copy of the furnished records. NO, I do not want a copy of the furnished records.
Signature:
(Not valid unless signed and dated) Date
*Mailing Address:
*Denotes required information – see instructions #3
Telephone:
FAA Form 8060-10A, Airman Notice And Right To Receive Copy -- FAA Records Request (PRIA), 04/2003 OMB No. 2120-0607
Appendix 3 Page 3 (and 4) FIGURE 1. (CONTINUED) FAA FORM 8060-10A, AIRMAN NOTICE AND RIGHT TO RECEIVE
COPY -- FAA RECORDS (PRIA) (BACK)
INSTRUCTIONS
FAA FORM 8060-10A, AIRMAN NOTICE AND RIGHT TO RECEIVE COPY -- FAA RECORDS (PRIA)
Pilot Records Improvement Act Of 1996 TITLE 49 U.S.C § 44703(h), Records of Employment of Pilot Applicants, As Amended
NOTICE
Request will not be deemed received or valid unless completed as specified below.
This form may be photocopied for use.
This form is available on the Internet at http://www.faa.gov/avr/afs/pria/ A separate form must be used for each airman whose records have been requested.
DO NOT enter information on this form such as date of birth, social security number, *home address, or other information in which the airman may have a reasonable expectation of privacy.
Part I: To be completed by the FAA Office receiving a FAA Records Request (PRIA).
NOTE: All entries must be either type written or printed legibly with black or dark blue ink.
1. Airman’s name and certificate number – enter the name and certificate number of the individual who is the subject of the request on FAA Form 8060-10, FAA Records Request (PRIA).
2. Air carrier name and certificate number -- enter the na me and certificate number of the air carrier making the request on FAA Form 8060-10, FAA Records Request (PRIA).
3. Date -- enter the date of the request listed on FAA Form 8060-10, FAA Records Request (PRIA).
Part II: To be completed by Airman/Applicant.
NOTE: All entries must be either type written or printed legibly with black or dark blue ink.
1. YES or NO -- check the appropriate box to indicate whether you DO or DO NOT want a copy of the records furnished. If requested, copies will be mailed to the mailing address provided.
2. Signature and date -- sign in ink using your legal signature and enter the date.
3. *Mailing address -- this information is required – provide a complete mailing address to which the FAA will mail a copy of the requested records.
4. Return completed copy to FAA.
PAPERWORK REDUCTION ACT STATEMENT
Title 49 United States Code (49 U.S.C.) § 44703(h), Records of Employment of Pilot Applicants, as amended, requires all air carriers to request FAA records and Air Carrier and Other Records concerning an individual before allowing that individual to begin service as a pilot. 49 U.S.C. § 44703(h)(8) requires the FAA Administrator to promulgate standard forms to request records. The information entered on the standard forms will be used to facilitate search and retrieval of the required records. It is estimated that the average burden per respondent associated with the collection of FAA Records (this collection) is 10 minutes. If you wish to comment on the accuracy of this estimate or submit suggestions for reducing the burden, you may write to: Federal Aviation Administration, Air Transportation Division, AFS-200, 800 Independence Avenue, SW, Washington, DC 20591. The requirement to collect background information on the pilots before allowing the pilot to begin service is mandatory; the use of this form is not. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The control number assigned to this collection is 2120-0607.
Appendix 4 APPENDIX 4. OVERVIEW OF FAA FORM 8060-11, AIR CARRIER AND OTHER
RECORDS REQUEST (PRIA)
Pilot Records Improvement Act Of 1996, As Amended
NOTICE: Request will not be deemed recei ved or valid unless Parts I and II are completed as specified in the instructions for the form.
1. Part I – Records Request (PRIA). Part I is used by the air carrier to request certain records of the pilot from any air carrier or other person that has employed the individual at any time during the 5-year period preceding the date of the employment application of the individual, or from the trustee in bankruptcy for such air carrier or other person. The records that must be provided are identified in 49 U.S.C. § 44703(h)(1)(B) and paragraph 8a of this AC.
2. Part II – Airman Consent to Release of Records. Part II is used by the air carrier to obtain written consent to the release of the records from the airman who is the subject of the records requested.
3. Furnishing Records. A person who receives a request for records under 49 U.S.C.
§ 44703(h) shall furnish a copy of all such requested records maintained by the person not later than 30 days after receiving the request.
4. Reasonable Charges. 49 U.S.C. § 44703(h)(7) allows for reasonable charges for processing requests and furnishing copies of requested records (see paragraph 8g above for further clarification).
Appendix 4 FIGURE 1. FAA FORM 8060-11, AIR CARRIER AND OTHER RECORDS REQUEST (PRIA) (FRONT)
AIR CARRIER AND OTHER RECORDS REQUEST (PRIA)
Pilot Records Improvement Act Of 1996 Title 49 U.S.C. § 44703(h), Records of Employment of Pilot Applicants, As Amended NOTICE Request will not be deemed received or valid unless Parts I and II are completed as specified in the instructions.
Pursuant to 49 U.S.C. § 44703(h)(5), a person who r eceives a request for records under 49 U.S.C. § 44703(h)(1) shall furnish a copy of all such requested records maintained by the person not later than 30 days after receiving the request.
PART I: AIR CARRIER AND OTHER RECORDS REQUEST (PRIA) To:
, , hereby requests (Air Carrier Name) (Air Carrier Certificate #) copies of records as required under 49 U.S.C. § 44703(h)(1)(B), as amended, pertaining to the airman consenting in Part II below.
Name: Title:
(Print – Air Carrier Representative) (Print—Title of Air Carrier Representative)
Signature:
Date:
(Air Carrier Representative) Mail Records To:
Telephone:
FAX:
PART II: AIRMAN CONSENT TO RELEASE OF RECORDS I , consent to and authorize my current or previous (Print – Airman’s First, Middle, and Last Name) employer to release records (Print—Employer Name) pertaining to me as required under 49 U.S.C. § 44703(h)(1)(B) to the air carrier named in Part I above.
Airman Certificate Number(s):
Signature:
Date:
*Mailing Address:
*Denotes required information – see instructions #4
Telephone:
FAA Form 8060-11, Air Carrier And Other Records Request (PRIA), Revised 04/2003 – Previous editions are obsolete OMB No. 2120-0607
Appendix 4 Page 3 (and 4) FIGURE 1 (CONTINUED). FAA FORM 8060-11, AIR CARRIER AND OTHER RECORDS REQUEST (PRIA) -- PILOT RECORDS IMPROVEMENT ACT OF 1996, AS AMENDED (BACK)
INSTRUCTIONS
FAA FORM 8060-11, AIR CARRIER AND OTHER RECORDS REQUEST (PRIA),
Pilot Records Improvement Act Of 1996 Title 49 U.S.C § 44703(h), Records of Employment of Pilot Applicants, As Amended Air carriers should use this form to request records from current and/or past employers as contemplated under 49 U.S.C. § 44703(h).
NOTICE
Request will not be deemed received or valid unless Parts I and II are completed as specified below.
Pursuant to 49 U.S.C. § 44703(h)(5), a person who receives a request for records under 49 U.S.C. § 44703(h)(1) shall furnish a copy of all such requested records maintained by the person not later than 30 days after receiving the request.
This form may be photocopied for use.
This form is available on the Internet at http://www.faa.gov/avr/afs/pria/.
A separate form must be used for each airman whose records are requested.
DO NOT use this form to request Pilot Records from the Federal Aviation Administration.
Part I: To be completed by the Air Carrier.
NOTE: All entries, except for signature, must be either type written or printed legibly with black or dark blue ink.
1. To – enter the address of the airman’s current and/or previous employer.
2. Name, title, and signature – enter the name, title, and signature of the person making the request on behalf of the air carrier.
3. Date – enter the date of the request.
4. Mailing address – provide a complete company mailing address to which the air carrier or person will mail the requested records.
Part II: To be completed by Airman/Applicant.
NOTE: All entries, except for signature, must be either type written or printed legibly with black or dark blue ink.
1. Name -- enter your name as it is shown on your airman certificate(s).
2. Airman Certificate Number -- enter your airman certificate number(s). In parenthesis after the certificate number, indicate the type of certificate by using S (Student), P (Private), C (Commercial), F (Flight Instructor), G (Ground Instructor), or A (Airline Transport Pilot). If you have multiple certificates with the same certificate number, list the certificate number once and indicate the types of certificates in parenthesis. For example, if you hold an Airline Transport Pilot Certificate as well as Flight Instructor and Ground Instructor Certificates using the same number, you should indicate as follows: Certificate No.
456231234 (A, F, G).
3. Signature and Date – Sign in ink using your legal signature and enter the date.
4. *Mailing Address -- This information is required to provide notice to the airman that a request for records has been received and of the airman’s right to receive a copy of the records provided to the carrier.
PAPERWORK REDUCTION ACT STATEMENT
Title 49 United States Code (49 U.S.C.) § 44703(h), Records of Employment of Pilot Applicants, as amended, requires all air carriers to request FAA records and Air Carrier and Other Records concerning an individual before allowing that individual to begin service as a pilot. 49 U.S.C. § 44703(h)(8) requires the FAA Administrator to promulgate standard forms to request records. The information entered on the standard forms will be used to facilitate search and retrieval of the required records . It is estimated that the average burden per respondent associated with the collection of Air Carrier and Other Records (this collection) is 30 minutes. If you wish to comment on the accuracy of that estimate or submit suggestions for reducing the burden, you may write to: Federal Aviation Administration, Air Transportation Division, AFS-200, 800 Independence Avenue, SW, Washington, DC 20591. The requirement to collect background in formation on the pilots before allowing the pilot to begin service is mandatory; the use of this form is not. An agency may not conduct or sponsor, and a person is not required to respo nd to, a collection of information unless it displays a currently va lid OMB control number. The control number assigned to this collection is 2120-0607.
Appendix 5 APPENDIX 5. OVERVIEW OF FAA FORM 8060-11A, AIRMAN NOTICE AND RIGHT TO RECEIVE COPY – AIR CARRIER AND OTHER RECORDS (PRIA)
Pilot Records Improvement Act Of 1996, As Amended
NOTICE: Request will not be deemed recei ved or valid unless Parts I and II are completed as specified in the instructions for the form.
1. Part I – Airman Notice And Right To Receive Copy – Air Carrier And Other Records (PRIA). Part I is used by an air carrier or person that has employed the pilot at any time during the 5-year period preceding the date of the employment application to notify the pilot:
a. That an Air Carrier And Other Records Request (PRIA) has been received, and
b. To notify the pilot of the pilot’s right to receive a copy of the records furnished to the requesting air carrier.
2. Part II – Airman Request Or Non-Request For Records. Part II is used by the Pilot to notify the air carrier or person whether or not he/she wants a copy of the records that were furnished to the requesting air carrier.
3. Furnishing Records. A person who receives a request for records under 49 U.S.C.
§ 44703(h) shall provide to the individual who is the subject of the records:
a. On or before the 20th day following the date of receipt of the request, written notice of the request and of the individual’s right to receive a copy of such records, and
b. Furnish a copy of all such requested records not later than 30 days after receiving the request.
4. Reasonable Charges. 49 U.S.C. § 44703(h)(7) allows for reasonable charges for processing requests and furnishing copies of requested records(see paragraph 8g above for further clarification).
Appendix 5 FIGURE 1. FAA FORM 8060-11A, AIRMAN NOTICE AND RIGHT TO RECEIVE COPY – AIR CARRIER AND OTHER RECORDS (PRIA) (FRONT)
AIRMAN NOTICE AND RIGHT TO RECEIVE COPY – AIR CARRIER AND
OTHER RECORDS (PRIA)
Pilot Records Improvement Act Of 1996 Title 49 U.S.C. § 44703(h), Records of Employment of Pilot Applicants, As Amended NOTICE
Title 49 U.S.C. § 44703(h)(6) requires the person receiving a records request to notify the individual who is the subject of the request within 20 days after receiving the request, and further entitles the individual the right to receive a complete copy of all air carrier an d other records furnished in response to the request within 30-days after receiving the request.
Title 49 U.S.C. § 44703(h)(7) allows for a reasonable ch arge for the cost of pr ocessing the request and furnishing copies of the requested records.
PART I: AIRMAN NOTICE AND RIGHT TO RECEIVE COPY
(Airman Name – First, Middle, Last) (Airman Certificate #) Pursuant to 49 U.S.C. § 44703(h)(6), you are hereby notified that , (Air Carrier Name) , submitted an Air Carrier And Other Records Request (PRIA), dated (Air Carrier Certificate # for your records as required under 49 U.S.C. § 44703(h)(1)(B), as amended.
(Date)
You are hereby notified of your right to receive a copy of any and all records furnished by the Air Carrier or Person in response to the aforementioned records request, and th at you may request a copy of such records by checking yes, signing, and dating in Part II below.
PART II: AIRMAN REQUEST OR NON-REQUEST FOR RECORDS YES, I want a copy of the furnished records. NO, I do not want a copy of the furnished records.
Signature: Date (Not valid unless signed and dated)
*Mailing Address:
*Denotes required information – see instructions #3
Telephone:
FAA Form 8060-11A, Airman Notice And Right To Receive Copy – Air Carrier And Other Records Request (PRIA), 04/2003 OMB No. 2120-0607
Appendix 5 Page 3 (and 4) FIGURE 1. (CONTINUED) FAA FORM 8060-11A, AIRMAN NOTICE AND RIGHT TO RECEIVE COPY – AIR CARRIER AND OTHER RECORDS (PRIA) (BACK)
INSTRUCTIONS
FAA FORM 8060-11A, AIRMAN NOTICE AND RIGHT TO RECEIVE COPY --
AIR CARRIER AND OTHER RECORDS (PRIA)
Pilot Records Improvement Act Of 1996 Title 49 U.S.C § 44703(h), Records of Employment of Pilot Applicants, As Amended
NOTICE
Request will not be deemed received or valid unless completed as specified below.
This form may be photocopied for use.
This form is available on the Internet at http://www.faa.gov/avr/afs/pria/.
A separate form must be used for each airman whose records are requested.
Part I: To be completed by the Air Carrier or Person receiving the Air Carrier And Other Records Request (PRIA).
NOTE: All entries must be either type written or printed legibly with black or dark blue ink.
1. Airman’s name and certificate number – enter the name and certificate number of the individual who is the subject of the request on FAA Form 8060-11, Air Carrier And Other Records Request (PRIA).
2. Air carrier name and certificate number -- enter the name and certificate number of the air carrier making the request on Air Carrier And Other Records Request (PRIA).
3. Date – enter the date of the request listed on FAA Form 8060-11, Air Carrier And Other Records Request (PRIA).
Part II: To be completed by Airman/Applicant.
NOTE: All entries must be either type written or printed legibly with black or dark blue ink.
1. YES or NO—check the appropriate box to indicate whether you DO or DO NOT want a copy of the records furnished. If requested, copies will be mailed to the mailing address provided.
2. Signature and date—sign in ink using your legal signature and enter the date.
3. *Mailing address -- This information is required to provide notice to the airman that a request for records has been received and of the airman’s right to receive a copy of the records provided to the carrier
4. Return completed copy to air carrier or person.
PAPERWORK REDUCTION ACT STATEMENT
Title 49 United States Code (49 U.S.C.) § 44703(h), Record s of Employment of Pilot Applicants, as amended, requires all air carriers to request FAA records and Air Carrier and Other Records concerning an individual before allowing that individual to begin service as a pilot. 49 U.S.C. § 44703(h)(8) requires the FAA Administrator to promulgate standard forms to request records. The information entered on the standard forms will be used to facilitate search and retrieval of the required records. It is estimated that the average burden per respondent associated with the collection of FAA Records (this collection) is 10 minutes. If you wish to comment on the accuracy of this estimate or submit suggestions for reducing the burden, you may write to: Federal Aviation Administration, Air Transportation Division, AFS-200, 800 Independence Avenue, SW, Washington, DC 20591.
The requirement to collect background information on the pilots before allowing the pilot to begin service is mandatory; the use of this form is not. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The control number assigned to this collection is 2120-0607.
Appendix 6 APPENDIX 6. NATIONAL DRIVER REGISTER (NDR) RECORD REQUEST
1. Part I – NDR Record Request. The NDR Record Request is used by the air carrier to request NDR records about an individual seeking employment with the air carrier. Forms can be obtained from the State motor vehicle agency where the air carrier is located. The National Highway Traffic Safety Administration (NHTSA) maintains an Internet database with current addresses and telephone numbers for State motor vehicle agencies This information may be accessed via the Internet at http://www.nhtsa.dot.gov/people/perform/driver/.
a. Probable Identification. The NDR will identify probable matches that require further inquiry for verification. It is strongly recommended that air carriers verify matches with State(s) of record.
b. Identification Information. Records received from the NDR will contain only identification information about the individual, provided by the State(s) that reported the information to the NDR. Specific information regarding the nature of the action that caused the individual to be listed on the NDR will not be provided. Such information should be requested by the air carrier from State(s) of record, after the air carrier verifies that the driver identified in the NDR record and the applicant are the same individual.
c. Period of Availability. Information will not be provided by the NDR if the information was reported to the NDR more than 5 years before the date of the request, unless the information relates to a suspension or revocation of driving privileges that is still in effect on the date of the request.
2. Part II - Consent to Request Records . Used to obtain written consent to the release of the records from the individual who is seeking employment with the air carrier. Requests will not be deemed received or valid if consent has not been provided.
a. To submit a request (with the consent) for the NDR check through a State chief driver licensing official, the individual must provide proof of identification in accordance with State procedures. Acceptable forms of identification may include a notarized signature or, if the consent is delivered by the individual in person, a driver’s license, birth certificate, credit card, employee identification card, or other form of identification normally accepted by the State.
3. Part III – Notice to Prospective Employee. Serves as notice to prospective employees:
(a) of the request; and (b) of their right to receive a copy of any records furnished by submitting a request for such records.
NOTE: Under the provisions of the Privacy Act, an individual may request his or her own report(s) at any time from the NDR office. An individual’s own report will include all records on th e individual and to whom they have been disclosed. States have different record retention requirements, e.g., 10 years. As a result, the individual’s report will include anything the State has on file.
Appendix 6 FIGURE 1. SAMPLE NATIONAL DRIVER REGISTER REQUEST
Name and Address of Air Carrier
PART I – NATIONAL DRIVER REGISTER (NDR) REQUEST This request authorizes the National Highway Traffic Safety Administration (NHTSA) to perform a one-time file search of the National Driver Register (NDR) for information pertaining to me, and to provide the results to the prospective employer listed on this form. This search is to be limited to information about revocations or suspensions still in effect on the date of the request or information entered in the NDR in the past 5 years from the date of the request. Upon my request, the prospective employer listed shall make available to me any NDR information received as a result of this search.
Type or Print Clearly (Inquiries that cannot be read will be returned to the air carrier)
Full Legal Name (First, Middle, Last)
Other Names Used (Maiden, Prior Name, Nickname, Professional Name, Other)
Date of Birth (MM/DD/YYYY)
Social Security Number (Optional) Driver’s License Number and State Sex
Eye Color Height Weight
PART II – CONSENT TO RELEASE RECORDS Prospective Employee Understanding: I understand that the National Driver Register (NDR) search will result in a printed report which will be sent only to the prospective employer listed on this form. The report will indicate either: (1) that the NDR does not contain a record matching my identification; or, (2) that the NDR has a probable identification (pointer record) from one state (or more) which w ill be named on this r eport. A separate check of state files would be required: (1) to verify the identification; or, (2) to obtain the driving record. Under the Privacy Act, I have the right to request record(s) pertaining to me from the NDR to verify their accuracy.
I hereby, with my notarized signature, authorize a one-time file search of the NDR and any resulting reports to be sent to the prospective employer named on this form.
_____________________________________________________ ______________________ Signature Date
PART III – NOTICE TO PROSPECTIVE EMPLOYEE Pursuant to Title 49 United States Code § 44703(h), Records of Employment of Pilot Applicants, as amended, this serves as notice of a request for NDR information concerning your motor vehicle driving record and your right to receive a copy of such information.
Official Use Only NOTARIZATION Date Received Date Sent Internal control Required only if the NDR File Check Request is not made in person by the prospective employee.
Type of Identification
! Valid Photo Driver License ! State-issued Photo ID ! Birth Certificate ! Valid Passport ! Valid Military ID ! Military discharge Papers ! Other (specify) _________________________
Sworn to and ascribed before me Notary Public this_____ day of_____________ Seal or Stamp 20_____ in the city/county ___________________________ State of_____________________ Employee Verifying Applicant Signature Identification (Print Name)
Appendix 7 Page 1 (and 2)
APPENDIX 7. AUTHORIZATION FOR RELEASE OF DOT DRUG AND ALCOHOL TESTING RECORDS UNDER PRIA AND MAINTAINED UNDER TITLE 49 CODE OF FEDERAL REGULATIONS (49 CFR) PART 40
AUTHORIZATION FOR RELEASE OF DOT DRUG AND ALCOHOL TESTING RECORDS UNDER PRIA AND MAINTAINED UNDER TITLE 49 CODE OF FEDERAL REGULATIONS (49 CFR) PART 40
Pilot Records Improvement Act Of 1996 Title 49 U.S.C. § 44703(h), Records of Employment of Pilot Applicants, As Amended Section I
To be completed by the new employer, signed by the employee, and transmitted to the previous employer
T O :
Previous Employer, Name
, City State
I, ______________________________________ SSN: ________________________ have applied for employment (Printed Name) with _____________________________________________, _______________________, and hereby authorize (Air Carrier Name – Printed) (Air Carrier Certificate Number) release of records from Department of Transportation-regul ated drug and alcohol testing of me by my previous
employer, to ______________________ _______________________ at this potential employer. This release (Name of the person authorized to receive the release of these records – Printed) is in accordance with DOT Regulation 49 CFR §40.25. I under stand that information to be released by my previous employer is limited to the following DOT regulated testing records:
1. Alcohol test results indicating an alcohol concentration of 0.02 or greater;
2. Verified positive drug test results;
3. Documentation of refusals to take required alcohol and/or drug tests (including substituted or adulterated drug test results);
4. Substance Abuse Professional (SAP) reports;
5. All follow-up tests and schedules for follow-up tests;
6. Information obtained from previous employer s under 49 CFR § 40.25 concerning drug and/or alcohol violations; and,
7. Records of negative and cancelled drug test results and alcohol test results with a concentration of less than
0.02.
Employee Signature: ___________________________________________ Date: _________________________
A reproduction of this authorization shall be deemed effective and valid as an original.
Applicants do not write below this line Section II
Name of person providing the requested records: __________________________________________________
T i t l e :
Phone #:
D a t e :
NOTE To Previous Employer If the individual named in Section I above has requested a copy of their records pursuant to a PRIA records request on FAA Form 8060-11A, AIRMAN NOTICE AND RIGHT TO RECEIVE COPY -- AIR CARRIER AND OTHER RECORDS (PRIA), copies of the Drug and Alcohol records must be provided to th e individual (Title 49 U.S.C. § 44703(h)(6)). Forward copies of t he Drug and Alcohol records to the address provided by the individual on FAA Form 8060-11A.