Fill and Sign the Declaration for Multi Day Fishing Trip Form

Form Approved: OMB No. 2120-0607 08/31/2010 AIR CARRIER AND OTHER 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 NOTICE Request will not be deemed valid unless Parts I and II are completed as specified in the instructions. Pursuant to 49 U.S.C. § 44703(h)(5), the Air Carrier, as a person who receives a request for records under 49 U.S.C. § 44703(h) (1)(B) shall furnish a copy of such requested records maintained by that person not later than 30 days after receiving the request. PART I: AIR CARRIER AND OTHER RECORDS REQUEST (PRIA) To: , (Air Carrier Name) , hereby requests copies of (Air Carrier Certificate Number) 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) Signature: (Print—Title of Air Carrier Representative) Date: (Air Carrier Representative) Mail Records To: Telephone: FAX: PART II: AIRMAN CONSENT FOR THE RELEASE OF RECORDS , consent to and authorize my current or previous I (Print – Airman’s First, Middle, and Last Name) to release records pertaining to employer (Print—Employer Name) 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: (Not valid unless signed and dated) *Mailing address: (*Indicates required information. See Instructions: Part II, item 4) Telephone: FAA Form 8060-11 (10-05) INSTRUCTIONS FAA FORM 8060-11, AIR CARRIER AND OTHER 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 records from current and/or past employers as contemplated under 49 U.S.C. § 44703(h). NOTICE Request will not be deemed 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 at http://www.faa.gov/pilots/lic_cert/pria/ or http://forms.faa.gov/ 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 – Air Carrier and Other Records Request (PRIA): To be completed by the hiring Air Carrier. All entries must be completed legibly with black or dark blue ink. 1. 2. 3. 4. To – enter the address of the airman’s previous employer. (Hiring air carrier may instruct the applicant to make this entry) Name, title, and signature – enter the name, title, and signature of the person making the request on behalf of the air carrier. Date – enter the date of the request. Mailing address – provide a complete company mailing address to which the air carrier or person will mail the requested records. Part II – Airman Consent For The Release Of Records: To be completed by Airman/Applicant. All entries must be completed 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 C (Commercial), A (Airline Transport Pilot), F (Flight Instructor) or G (Ground Instructor). 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, then enter the date of the request. 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 requesting air 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 the search and retrieval of the required records. It is estimated that the average burden per respondent associated with this collection of Air Carrier and Other Records is 30 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. Comments concerning the accuracy of this burden and suggestions for reducing the burden should be directed to the FAA at: 800 Independence Ave SW, Washington, DC 20591, Attn: Information Collection Clearance Officer, ABA-20 . FAA Form 8060-11 (10-05)