Pilots Convicted of Alcohol or Drug-Related Motor Vehicle Offenses or Subject to State Motor Vehicle Administrative Procedure

Paperwork Reduction Act Burden Statement. A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the
requirements of the Paperwork Reduction Act unless that collection of information displays a currently valid OMB Control Number. The OMB Control Number for this information collection is 2120-0543. Public reporting for this collection of
information is estimated to be approximately (10) minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, completing and reviewing the collection of information.
All responses to this collection of information are mandatory (per Title 14 Part 61.15(e); however the use of the downloadable template is optional. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden to: Information Collection Clearance Officer, Federal Aviation Administration, 10101 Hillwood Parkway, Fort Worth, TX 76177-1524

Notification Letter
Use this document to report driver’s license actions and convictions only. Arrests are only required to
be detailed on your Application for Medical Certificate, FAA Form 8500-8.
Call 405-954-4848 for assistance in filling out this form.

Date: ______________________
1.

NAME: __________________________________________________________________
(Last Name, First Name, Middle Name or Initial)

2.

DATE OF BIRTH: _______________________________

3.

CERTIFICATE #: _______________________________

4.

ADDRESS:

___________________________________________________________
(Street Number/Name, Post Office Box, RFD…etc.)
___________________________________________________________
(City, State, Zip Code)

5.

TELEPHONE NUMBER: __________________________

6.

Have you received an Alcohol and/or Drug Related Suspension/Revocation against your driver’s license?
(Chemical Test Results, Refusal to Test)

Yes

No

DATE OF SUSPENSION/REVOCATION:__________________________
STATE HOLDING RECORD:__________________________
DRIVER’S LICENSE NUMBER or ASSIGNED ID NUMBER IF NOT LICENSED IN THE STATE WHERE THE
VIOLATION OCCURRED:
__________________________________________________________________________
7.

Have you been convicted of an alcohol and/or Drug related offense?
(DUI,DWI, OUI, OWI, DWAI, etc.)

Yes

No

DATE OF CONVICTION:__________________________________________________________
STATE HOLDING RECORD:______________________
COURT LOCATION: __________________________________________________________
8.

STATEMENT: (Is this action related to a previously reported action or is this a result of a separate “new” incident?)
__________________________________________________________________________
__________________________________________________________________________

_______________________________________________
(Signature)
You may print this document and submit via:
mail: FEDERAL AVIATION ADMINISTRATION

OR

fax: (405) 954-4989

SECURITY & HAZARDOUS MATERIALS SAFETY
REGULATORY INVESTIGATIONS DIVISION (AXE-700)
P. O. BOX 25810
OKLAHOMA CITY, OK 73125

OMB CONTROL NUMBER: 2120-0543
EXPIRATION DATE: 04/30/2018