Notification Letter To Report Driver'S License Actions And Convictions - Federal Aviation Administration Security & Investigations Division
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1Notification Letter
Use this document to report driver's license actions and convictions only.
1
Arrests are only required to be detailed on your Application for Medical Certificate, FAA Form 8500-8.
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 Related Suspension/Revocation against your driver's license? Yes No
(Refuse to test, BAC* over legal limit,etc.) * Blood Alcohol Content
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 related offense? Yes No
(DUI,DWI, OUI, OWI, DWAI, etc.)
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:
fax: (405) 954-4989
FEDERAL AVIATION ADMINISTRATION
OR
SECURITY & INVESTIGATIONS DIVISION (AMC-700)
P. O. BOX 25810
OKLAHOMA CITY, OK 73125
1
A Motor Vehicle Action is ANY alcohol/drug related administrative action taken against a person's state driver's license-(including
suspensions, cancellations, revocations, or denials of a license to operate a motor vehicle), and/or conviction for an alcohol related
motor vehicle offense.
Dr. Robert Gordon
965 South Main Street Plymouth, MI
734.455.3530
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