Fillable DRONE (UNMANNED AIRCRAFT SYSTEMS UAS) OPERATION PERMIT REQUEST (Gateway Technical College)

Fill Online, Printable, Fillable, Blank DRONE (UNMANNED AIRCRAFT SYSTEMS UAS) OPERATION PERMIT REQUEST (Gateway Technical College) Form

Use Fill to complete blank online GATEWAY TECHNICAL COLLEGE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

DRONE (UNMANNED AIRCRAFT SYSTEMS UAS) OPERATION PERMIT REQUEST (Gateway Technical College)

On average this form takes 7 minutes to complete

The DRONE (UNMANNED AIRCRAFT SYSTEMS UAS) OPERATION PERMIT REQUEST (Gateway Technical College) form is 3 pages long and contains:

  • 0 signatures
  • 18 check-boxes
  • 20 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Gateway Technical College

BROWSE GATEWAY TECHNICAL COLLEGE FORMS
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Page 1 of 3
H:\#data\Insurance\Drones\Forms\Unmanned Aircraft Systems Request Form - 08 09 18.docx
DRONE (UNMANNED AIRCRAFT SYSTEMS – UAS) OPERATION PERMIT REQUEST FORM
FOR INDIVIDUALS / ENTITIES NOT AFFILIATED WITH GATEWAY TECHNICAL COLLEGE
This Drone Operation Permit Request Form must be completed and submitted to Tom Cousino, Associate Vice President,
Facilities and Security, at cousinot@gtc.edu for review prior to each proposed UAS operation on Gateway Technical College
property or at any Gateway Technical College sponsored event. Individuals / Entities who are not affiliated with the College (or
who are not conducting Gateway Technical College sponsored operations) must submit this document not less than thirty (30)
business days in advance of flight operations. The Requestor will receive a response within 14 business days of request receipt.
Prior to submission of this form, the Requestor must review the Unmanned Aerial Systems (UAS) aka Drones Policy and
Procedures, Policy E-137 (available at https://www.gtc.edu/safety-security/campus-public-safety). Any omission of information
requested in this form may result in a delay of processing.
SECTION 1: REQUESTOR INFORMATION
Applicant Full Name: First ______________________ M.I. ________ Last ________________________________
Affiliation: Gateway Technical College ______ Non-Gateway Technical College ______
Department/Sponsor or Organization: ______________________________________________________________
Mailing Address: _______________________________________________________________________________
Contact Phone: ____________________________ Email Address: _______________________________________
SECTION 2: PURPOSE OF UAS REQUEST/PROPOSED ACTIVITY
Provide full details of flight purpose (education, coursework, research, promotional, etc), including identify of UAS operator(s).
Depending on your intended use and activities associated with the use of your UAS, other college approvals may be required
before you can operate your UAS on college property or at a college-sponsored event. For example, any proposed videography,
photography or recording must be approved through Gateway Technical College Marketing department and may be subject to a
review prior to release and/or publication.
Location of Request ________________________________________________________________________________________
Date(s) of UAS Activity ________________________ Starting Time _________________ Ending Time _____________________
SECTION 3: UAS DESCRIPTION
Type/Model of UAS _________________________________________________________________________________________
Weight/Dimensions ___________________________________________ Power Source/Serial # __________________________
Page 2 of 3
H:\#data\Insurance\Drones\Forms\Unmanned Aircraft Systems Request Form - 08 09 18.docx
DRONE (UNMANNED AIRCRAFT SYSTEMS – UAS) OPERATION PERMIT REQUEST FORM
FOR INDIVIDUALS / ENTITIES NOT AFFILIATED WITH GATEWAY TECHNICAL COLLEGE
Previous Request Approved Yes ___ No ___ If Yes, date of previous approval ___________________________________
UAS Registered with FAA Yes ___ No ___ If Yes, registration number _______________________________________
UAS Registered with ODA Yes ___ No ___ If Yes, registration number _______________________________________
Photos taken during flight Yes ___ No ___ Video recorded during flight Yes ___ No ___
Equipped with Geo-fencing Yes ___ No ___ Operating under a COA Yes ___ No ___
I have attached a Certificate of Waiver or authorization (COA), FAA Section 333 Exemption, Part 107 Remote Pilot Certificate
confirmation, Part 107 Waiver/Airspace Authorization, and/or other relevant documentation for this request.
SECTION 4: UAS OPERATOR RELEASE, WAIVER OF LIABILITY AND HOLD HARMLESS ACKNOWLEDGEMENT AGREEMENT
By signing below, the individual/entity submitting this request agrees to and will abide by all Gateway Technical College policies
and procedures governing the use of UAS on or over Gateway Technical College property or a Gateway Technical College
sponsored event. A copy of the approved Drone (UAS) Operation Permit Request form must be in possession of the operator at
all times during the activity, and upon request, must be presented to any Gateway Technical College official or representative
with control or jurisdiction over the activity. Gateway Technical College reserves the right to request additional documentation
as a condition of approval and operation. In addition, any operator violating any portion of Gateway Technical College’s policies
or procedures will be held accountable for their actions.
By signing below, the individual/entity submitting this request does hereby fully release and discharge Gateway Technical College
and any of its present or former Board of Trustees/Directors, administrators, officers, employees, teachers, agents and insurers,
and its and their predecessors, successors and assigns (collectively, Gateway Technical College entities) from any and all liability,
claims, and causes of action for any physical or mental injury or death, illness or other damages or loss which may result from
participation in the proposed UAS operation on Gateway Technical College property or at a Gateway Technical College sponsored
event, including, but not limited to, that which may arise out of Gateway Technical College entities’ own negligence. This is a
complete and irrevocable release and waiver of liability. This release does not apply to any intentional or reckless acts by
Gateway Technical College entities.
Individual/entity submitting this request further agrees not to sue Gateway Technical College entities for any alleged liabilities,
claims, or causes of action released hereunder. Signer promises to reimburse, indemnify and hold harmless Gateway Technical
College entities for any and all liability that may be asserted against them for any and all loss, damage or claim whatsoever,
including for claims seeking recovery based upon Gateway Technical College entities’ own actual or alleged negligence, relating
to any alleged liabilities, claims or causes of action released hereunder.
This UAS Operator Release, Waiver of Liability and Hold Harmless Acknowledgement Agreement shall be governed by the laws of
the State of Wisconsin, which shall be the forum for any lawsuits filed under, or incident to, this agreement.
Signature _________________________________________________________________ Date _________________________
Page 3 of 3
H:\#data\Insurance\Drones\Forms\Unmanned Aircraft Systems Request Form - 08 09 18.docx
DRONE (UNMANNED AIRCRAFT SYSTEMS – UAS) OPERATION PERMIT REQUEST FORM
FOR INDIVIDUALS / ENTITIES NOT AFFILIATED WITH GATEWAY TECHNICAL COLLEGE
SECTION 5: SAFETY AND RISK SERVICES RESPONSE
Request Approved Yes ___ No ___
Facilities and Security comments or requirements for operation are listed below and must be observed. If the request is not
approved, a summary of the decision is outlined below. Denial of a request to operate a UAS may be appealed in writing within
10 days of the denial to the Associate Vice President, Facilities and Security or their designee.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

DRONE (UNMANNED AIRCRAFT SYSTEMS UAS) OPERATION PERMIT REQUEST (Gateway Technical College)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 9 October 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document