PRIVACY ACT NOTICE
General - This information is provided pursuant to Public Law 93-579 (Privacy Act of 1974), December 31, 1974, for individuals supplying information for
inclusion in a system of records.
Authority - The authority to collect the information on the attached form is contained in 5 USC 552A.
Purpose and Use - This information, along with data you may have supplied previously, and information developed by investigation will be for use by
1. To determine your pilot qualifications to comply with contract specifications.
2. Transfer to the U.S. Department of Justice in the event of litigation.
3 Transfer, in the event there is indicated violation or potential violation of a statute, regulation, whether civil, criminal, or regulatory in nature, to the
appropriate agency or agencies, whether Federal, State, local, or foreign, charged with the responsibility of investigation or prosecuting such
violation or charged with enforcing or implementing the statute, rule, regulation, order, or license violated or potentially violated.
I. Applicant Information
a. Pilot Name (Last, First) – Self-explanatory.
b. Office Telephone - Self-explanatory.
c. E-mail – Company or email address used for business.
d. Employer – The Company that holds the contract.
e. Previous Employer – Only required if a pilot card was issued to the pilot while employed.
f. PIC HELICOPTER – Provide Pilot-in-Command time as required by the contract. Additional documentation of flight time may be required.
Ldgs=Number of landings.
g. PILOT HISTORY – Self-explanatory.
h. 14 CFR 135 QUALIFICATIONS - Self-explanatory.
i. OTHER FAA 14 CFR DOCUMENTATION – Provide dates completed for FAA required training and/or evaluations. Be prepared to present
documentation to an OAS pilot inspector as required.
j. M M & Series – Make, Model & Series. VTR – Vertical Reference flight time, flight time acquired while maneuvering this MM&S helicopter via
vertical reference. Mtn – Mountainous terrain flight time acquired in this MM&S at and below 1000 feet within designated mountainous areas defined
by 14 CFR 95 Subpart B, 12 mo – Flight time in this MM&S within the previous 12 calendar months, Hours – PIC time in this MM&S. It may be
necessary to provide additional MM&S within a make and model family to document required make and model time.
k. Applicant Remarks – Add anything you feel is pertinent.
l. Self-explanatory – Electronic signatures are acceptable.
m. Company Official must be Director of Operations, Chief Pilot or equivalent. First box must always be checked. The second box is only
required when applicant is
vertical reference longline approved or seeking evaluation. Electronic signatures are acceptable.
II. Inspector Information:
a. Checklist of Documents Verified by the Inspector – A checked box indicates that you, the inspector, looked at the required documents and then
returned them to the applicant. Provide expiration date as required.
b. Check if applicant is approved and attach a copy of the OAS-30B/5700-3A issued to the applicant.
c. Check if applicant is not approved and add any required comments in the remarks section.
d. Electronic signatures are acceptable
e. Add any comments necessary.