Unmanned Aerial Systems Questionnaire

Section 1: Applicant Information

Name of Applicant:

Organization (if applicable):

Address:

City, State, ZIP:

Email:

Phone:

Valid Driver’s License?:
YesNo
Driver's License:

Section 2: Drone Operator Details

Name of Operator:

Type of Request:
Internal (CMN)External
FAA Part 107 Certified?:
YesNo
FAA Certification:

Section 3: UAS (Drone) Details

Drone Manufacturer & Model:

Drone Serial Number:

Maximum Takeoff Weight (lbs/kg):

FAA Registration Number (if applicable):

Attach picture of Remote ID:

Section 4: Flight Details

Purpose of Flight:
CommercialRecreationalResearchGovernmentOther (specify):
Other (specify):

Flight Date(s) Requested: Must be at least 2 weeks from today's date.

Flight Location (Address/Coordinates):

Section 5: Safety & Privacy Compliance

Emergency Procedures in Place?:
YesNo
Liability Insurance Coverage?:
YesNo
Proof of Insurance:

Will Flight Involve Capturing Images/Videos?:
YesNo
If yes, how will privacy concerns be addressed?:

Section 6: Acknowledgment & Agreement

I acknowledge that I have read and understood all local, state, and federal drone regulations and agree to comply with all applicable laws and safety measures. I assume full responsibility for any damages or liabilities arising from the operation of the UAS under this request.
Date: