pria_forms.pdf
Members of the National Air Transportation Association ~ Qualify for 10% Discount off Background Check Service Items
SECTION A: COMPANY INFORMATION 1. Company Name 2. Client ID #
(required) 3. Address 4. City 5. State 6. Postal Code
7. Company Contact Name & Title
8. Email
9. Direct Phone & Extension 10. Secured Fax Number
SECTION B: EMPLOYEE / APPLICANT INFORMATION 1. Last Name 2. First Name 3. Middle Name 4. Address 5. Birthdate * 6. City 7. State 8. Postal Code
9. Position 10. Social Security Number *
SECTION C: REQUEST SERVICE TYPE (BACKGROUND CHECK PACKAGES)
SECTION D: ADDITIONAL SERVICES
SECTION E: SERVICE REPORTS METHOD OF DELIVERY / NOTES
9400 Gateway Drive, Suite D, Reno NV 89521 800.788.3210 voice | 800.682.1969 fax | 703.842.5317 int’l www.NATACS.aero
1.) 2 Year Drug & Alcohol History $69.95 • 2 Year DOT Drug & Alcohol History
Check (Covers all DOT employers within 2-year period)
2) Basic PRIA Package 2 & 3 $199.95 • National Driver Registry • 5 Year DOT Drug & Alcohol
History Check • FAA Records Check • Air Carrier Records Check
3) DASSP Airman $59.95 • DASSP Airman File
Check
1. U.S. Employment Verification per employer 1 & 3 $21.95 2. Motor Vehicle Driving Record Check 1 & 3 $32.95
3. FAA Records Check $35.95 4. National Driver Registry 2 $49.95
5. Air Carrier Records Check per employer 3 $35.95 6. FAA Certificate/License Check $29.95
7. 5 Year DOT Drug & Alcohol History Check per employer $39.95 8. FAA Accident, Incident and Enforcement (AIE) Report $59.95
All forms, verifications and reports are posted on www.NATACS.aero. Company authorized contact may access via secured login. 1 A $25.90 application-processing fee will be charged for web-enabled services per employee/applicant. 2 NDR documents with original signatures must be MAILED to NATACS for processing. 3 Direct pass-through expenses shall be invoiced. * If information has been previously entered into the system, only the last four digits of the SSN are required. If the employee/applicant is new to the system, the full SSN and birthdate are required.
Questions? CALL +1.703.842.5317 FAX 1.866.768.2881 (alt) 1.800.682.1969 or
Email services@NATACS.aero or Mail: 9400 Gateway Drive, Suite D, Reno, NV 89521
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9400 Gateway Drive, Suite D Reno, NV 89521 800.788.3210 voice www.NATACS.aero
Drug and Alcohol History Check (ref: 49 CFR Part 40.25b) This section requires DOT-regulated operator to check the record of the new employees who were previously employed by a company subject to DOT regulations.
Part I Section I: To be completed & signed by the employee/applicant
PART I
I. EMPLOYEE/APPLICANT:
Employee Printed or Typed Name Employee Social Security Number
1. I have been employed by one (or more) DOT-regulated company and subject to DOT regulations within the last 5 years. (Check one.)
Yes No
If “Yes”, provide name(s) of DOT-Regulated employer(s) and complete the attached release form for each DOT-regulated company.
DOT-Regulated Employer:
DOT-Regulated Employer:
DOT-Regulated Employer:
DOT-Regulated Employer:
DOT-Regulated Employer:
2. I have tested positive, or refused to test, on any pre-employment drug or alcohol test administered by a DOT-regulated employer to which I have applied for, but did not obtain, safety-sensitive transportation work covered by the DOT agency drug and alcohol testing rules during the past two years. (Check one.)
Yes No
Address:
City,State,Zip:
Phone:
Fax:
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INSTRUCTIONS
FAA FORM 8060-13, NATIONAL DRIVER REGISTER RECORDS REQUEST (PRIA)
Pilot Records Improvement Act Of 1996 (PRIA) Title 49 U.S.C § 44703(h), RECORDS OF EMPLOYMENT OF PILOT APPLICANTS, as amended
Air carriers should use this form to request the appropri ate records from the National Driver Registry as contemplated under 49 U.S.C. § 44 703(h). Complete Instructions for t he use of thi s form, as well as proced ural information concerning the request of NDR records, are provided on the official PRIA website as listed below.
NOTICE Request will not be deemed valid unless Parts I, II, and III are completed as specified below. This form may be photocopied for use. This form is available on the Internet at http://www.faa.gov/pilots/lic_cert/pria/ or http://www.forms.faa.gov/ A separate form must be used for each airman whose records are requested. Use of the date of birth, social security number, or other information for which there may be a reasonable expectation of privacy, is optional. However, use of this information, at the applicant’s discretion, could facilitate the retrieval of the appropriate records required by this request IAW PRIA. (See the Privacy Act Statement)
Part I – National Driver Register (NDR) Records Request: To be completed by the hiring Air Carrier. All entries must be completed legibly with black or dark blue ink.
The hiring air carrier enters their name and air carrier certificate number. Personal information concerning the applicant is then entered into the respective spaces, with the date-of-birth and social security number being disclosed ONLY at the discretion of the applicant. The air carrier must ensure that complete mailing instructions are included with this request. Part II – Consent To The Release Of Records: To be completed by the applicant. All entries must be completed legibly with black or dark blue ink. The applicant must read and understand the statement, and then authorize the request and release of the appropriate NDR records by signing and dating the form in the indicated spaces. A notarized signature MAY be required by the state. Part III – Notice To The Prospective Employee. The air carrier representative must ensure that the applicant is aware that a request for the appropriate NDR records will be made IAW PRIA, and that a copy of the records, once received, will be furnished to the applicant if they so desire. A legible copy of this form must be furnished to the applicant after being completed and signed. ID verification in III(a) is to be completed by the air carrier representative when the application is made in person. ID verification in III(b) is to be completed when the application is NOT made in person. The respective state MAY also require a notarized signature.
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 the search and retrieval of the required records. It is estimated that the average burden per respondent associated with this collection of FAA Records is 10 minutes. The requirement to collect and evaluate background information on the pilot, before allowing that pilot to begin service, is mandatory; however, the use of this form is not, although it is highly recommended. An agency may not conduct or sponsor, and a person is not required to respond to, this request for information unless a current and valid OMB control number is prominently displayed. The OMB control number assigned to this collection is 2120-0607.
SEE PRIVACY ACT INFORMATION BELOW
FAA Form 8060-13 (10-05)
PRIVACY ACT STATEMENT: This statement is provided pursuant to the Privacy Act of 1974, 5 USC § 552a: The authority for collecting this information is contained in 49 U.S.C. §§ 40113, 44702, 44703, 44709. The principal purpose for which the information is intended to be used is to identify and evaluate your qualifications and eligibility for the issuance of an airman certificate and/or rating. Submission of the data is mandatory, except for the Social Security Number, which is voluntary. Failure to provide all required information will result in our being unable to issue you a certificate and/or rating. The information collected on this form will be included in a Privacy Act System of Records known as DOT/FAA 847, titled “Aviation Records on Individuals” and will be subject to the routine uses published in the System of Records Notice (SORN) for DOT/FAA 847 (see www.dot.gov/privacy/privacyactnotices), including: (a) Providing basic airmen certification and qualification information to the public upon request; examples of basic information include: • The type of certificates and ratings held, limitations, date of issuance and certificate number; • The status of the airman’s certificate (i.e., whether it is current or has been amended, modified, suspended or revoked for any reason); • The airman’s home address, unless requested by the airman to be withheld from public disclosure per 49 U.S.C. 44703(c); • Information relating to an airman’s physical status or condition used to determine statistically the validity of FAA medical standards; and the date, class, and restrictions of the latest physical • Information relating to an individual’s eligibility for medical certification, requests for exemption from medical requirements, and requests for review of certificate denials. (b) Using contact information to inform airmen of meetings and seminars conducted by the FAA regarding aviation safety. (c) Disclosing information to the National Transportation Safety Board (NTSB) in connection with its investigation responsibilities. (d) Providing information about airmen to Federal, State, local and tribal law enforcement agencies when engaged in an official investigation in which an airman is involved. (e) Providing information about enforcement actions, or orders issued thereunder, to Federal agencies, the aviation industry, and the public upon request. (f) Making records of delinquent civil penalties owed to the FAA available to the U.S. Department of the Treasury and the U.S. Department of Justice (DOJ) for collection pursu- ant to 31 U.S.C. 3711(g). (g) Making records of effective orders against the certificates of airmen available to their employers if the airmen use the affected certificates to perform job responsibilities for those employers. (h) Making airmen records available to users of FAA’s Safety Performance Analysis System (SPAS), including the Department of Defense Commercial Airlift Division’s Air Car- rier Analysis Support System (ACAS) for its use in identifying safety hazards and risk areas, targeting inspection efforts for certificate holders of greatest risk, and monitoring the effectiveness of targeted oversight actions. (i) Making records of an individual’s positive drug test result, alcohol test result of 0.04 or greater breath alcohol concentration, or refusal to submit to testing required under a DOT-required testing program, available to third parties, including current and prospective employers of such individuals. Such records also contain the names and titles of indi- viduals who, in their commercial capacity, administer the drug and alcohol testing programs of aviation entities. (j) Providing information about airmen through the Civil Aviation Registry’s Comprehensive Airmen Information System to the Department of Health and Human Services, Office of Child Support Enforcement, and the Federal Parent Locator Service that locates noncustodial parents who owe child support. Records in this system are used to identify airmen to the child support agencies nationwide in enforcing child support obligations, establishing paternity, establishing and modifying support orders and location of obligors. Records listed within the section on Categories of Records are retrieved using Connect: Direct through the Social Security Administration’s secure environment. (k) Making personally identifiable information about airmen available to other Federal agencies for the purpose of verifying the accuracy and completeness of medical information provided to FAA in connection with applications for airmen medical certification. (l) Making records of past airman medical certification history data available to Aviation Medical Examiners (AMEs) on a routine basis so that AMEs may render the best medical certification decision. (m) Making airman, aircraft and operator record elements available to users of FAA’s Skywatch system, including the Department of Defense (DoD), the Department of Homeland Security (DHS), DOJ and other authorized Federal agencies, for their use in managing, tracking and reporting aviation-related security events. (n) Other possible routine uses published in the Federal Register (see Prefatory Statement of General Routine Uses for additional uses (65 F.R. 19477-78) For example, a record from this system of records may be disclosed to the United States Coast Guard (Coast Guard) and to the Transportation Security Administration (TSA) if information from this system was shared with either agency when that agency was a component of the Department of Transportation (DOT) before its transfer to DHS and such disclosure is necessary to accomplish a DOT, TSA or Coast Guard function related to this system of records.
FAA Form 8060-13 (10-05)
REGISTER RECORDS CHECK (NDR)
Who: State of Florida Department of Highway Safety and Motor Vehicles will no longer process out-of-state Requests for National Driver Register (NDR) File Checks on Current or Prospective Employee of Air Carriers.
What: Processing of NDR will require a New Form 8060-13, available via http://info.natacs.aero/support/order-forms
When: Starting October 25, 2016, NATACS will no longer process the State of Florida NDR form.
Where: New Form 8060-13 is available via http://info.natacs.aero/support/order- forms
How: All requests must use form 8060-13 and *** ALL requests must be notarized ***
Why: This new process will REDUCE the turn time for employers to receive results.
Need Assistance? Call 1.703.842.5317 or email info@NATACS.aero
NATIONAL DRIVER REGISTER RECORDS REQUEST (PRIA) Pilot Records Improvement Act Of 1996 (PRIA)
Title 49 U.S.C. § 44703(h), RECORDS OF EMPLOYMENT OF PILOT APPLICANTS, as amended
Pursuant to 49 U.S.C. § 44703(h)(5), the NDR, as a person who receives a request for records under 49 U.S.C. § 44703(h)(1)(C), shall furnish a copy of the requested NDR records concerning all applicants, not later than 30 days after receiving the request.
PART I: NATIONAL DRIVER REGISTER (NDR) RECORDS 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 below. This search is to be limited to information about revocations or suspensions still in effect on the date of the request or information entered into the NDR in the past 5 years from the date of the employment application. Upon my written request, the prospective employer listed below shall make available to me any NDR information received as a result of this search.
_______________________________________________ , ________________________ , hereby requests records pertaining to: (Air Carrier Name) (Air Carrier Certificate #)
____________________________________ , ___________________________ , _____________________________ (Full Legal Name – first, middle, last) (Date Of Birth) (Social Security Number – optional)
________________________________________________________________________________________________ (Other Names Used – maiden prior name, nickname, professional name, other. If none, enter ‘none’)
______________________________________ , _______ , _______________ , _______________ , _____________ (Driver License Number and State) (Gender) (Eye Color) (Height) (Weight)
________________________________________________________________________________________________ (Mail the completed report to the requesting air carrier at this address) PART II: CONSENT TO THE RELEASE OF RECORDS Prospective Employee Understanding: I understand that the National Driver Register (NDR) search will result in a printed report, which shall be sent only to the prospective employer listed on this form. The report will indicate either: (1) that the NDR does not contain a records matching my identification; or, (2) that the NDR has a probable identification (pointer record) from one or more states, which will be named on this report. A separate and additional check of state files, as a result of the pointer record, 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 records pertaining to me from the NDR to verify their accuracy.
With my notarized signature, (If notarization is required) I hereby authorize a one-time file search of NDR related records pertaining to me, with any and all resulting reports to be sent to the prospective employer named in Part I of this form.
__________________________________________________________________ ______________________________ (Signature Of Applicant) (Date Of Signature)
PART III: NOTICE TO THE PROSPECTIVE EMPLOYEE Pursuant to Title 49 (U.S.C.) § 44703(h)(6) Records of Employment of Pilot Applicants, as amended, you are hereby notified, by being provided with a completed copy of this form, that the above air carrier will submit an FAA Records Request (PRIA) for your NDR related records. You are also notified of your right to receive a copy of any and all such records furnished by the NDR.
III(a). For Official ID Verification III(b). Notarization Date Received: Date Sent: Internal Control: Required only if the NDR File Check Request is NOT made in
person by the prospective employee, or by the respective state. ___Valid Photo Driver License ___State Issued Photo ID ___Birth Certificate ___Valid Passport ___Valid Military ID ___Military Discharge ___Other ___________________________________________
(Indicate the specific type of identification used.) ___________________________________________________ Printed name and signature of person verifying identification.
Sworn to and ascribed before me this_____day of __________ In the city/county of_______________________state of_____
Signature of Notary Public_____________________________ Notary Public Seal:
NATA Compliance Services, 9400 Gateway Drive, Suite D, Reno NV 89521
C/O NATA Compliance Services
Airman Certificate Number:
YES 2: Off
NO 2: Off
NO 3: Off
YES 3: Off
YES 4: Off
NO 4: Off
Air Carrier Representative:
8 Email:
Date Of Birth:
Social Security Number optional:
Other Names Used maiden prior name nickname professional name other If none enter none:
Driver License Number and State:
Gender:
Height:
Weight:
Mail the completed report to the requesting air carrier at this address:
Date Received:
Date Sent:
Internal Control:
In the citycounty of:
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