National Driver Register Authorization Form

The following release authorizes the National Driver Register to release adverse driver history information, if any, about you to the FAA. By completing the following release, you permit the FAA to request information, if any, pertaining to your driving record from the National Driver Register (NDR). Since the NDR identifies only probable matches, the FAA will verify the NDR information it receives with the state of record. You have the right to request an NDR file check to determine if it contains any information and, if so, the accuracy of such information. Notarized requests may be sent to: DOT/NHTSA/NTS32, 400 7th street, S.W., Washington, DC 20590 -0001, and must contain your complete name and date of birth. Other information about height, weight, and eye color will ensure correct positive identification.

Attestation Statements

  • I certify that I am under the care and treatment of a physician if I have been diagnosed with any medical condition that may impact my ability to fly.
  • I certify that I am under the care of a State-licensed medical specialist if I have a clinically diagnosed neurological condition.
  • I certify that I am under the care of a State-licensed medical specialist if I have a clinically diagnosed mental health condition.
  • I certify that to the best of my knowledge, the Comprehensive Medical Examination Checklist (CMEC) was followed and signed by the physician who performed the comprehensive medical examination.
  • I understand that I cannot act as pilot in command, or any other capacity as a required flight crew member, if I know or have reason to know of any medical condition that would make me unable to operate the aircraft in a safe manner.

This course also qualifies for FAA Wings credit.

When registering for the course, please enter the email address associated with your account to ensure it is reported correctly.

* These fields are required

pilot data

Pilot First Name

Pilot Last Name

Date of Birth

Address Line 1


Address Line 2


Zip Code

Pilot Phone Number

Pilot Certificate Number


Confirm Password

Password must be at least 6 characters long and contain one letter and one number.
physician data

Physician First Name

Physician Last Name

Physician Street Address Line 1

Physician Street Address Line 2

Physician City

Physician Zip Code

Physician Medical License #

Physician's Phone Number

Date physical exam completed