![](media/image1.wmf){width="2.3in" height="0.7798611111111111in"} **DC
FRZ Waiver Request**

**INSTRUCTIONS**: To request a waiver to enter the Flight Restricted
Zone (FRZ) in the District of Columbia, you must fax this completed form
to (571) 227-1945. Waiver requests require a minimum of 10 business days
to process. Incomplete or illegible information will result in delays in
the processing and/or denial of this request.

**NOTE: Requestor must be able to attest to all information in the
request based upon personal knowledge.**

<table>
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<col style="width: 13%" />
<col style="width: 0%" />
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<tbody>
<tr class="odd">
<td colspan="18"><strong>Section I. Requestor/Third-Party
Information</strong> <em>(Third party includes any requestor other than
the operator/owner.)</em></td>
</tr>
<tr class="even">
<td colspan="6">Previous Waiver Number <em>(if applicable)</em>:</td>
<td colspan="12">     </td>
</tr>
<tr class="odd">
<td colspan="9">Name of Approved TSA Aviation Security Program <em>(if
applicable)</em>:</td>
<td colspan="9">     </td>
</tr>
<tr class="even">
<td colspan="18"></td>
</tr>
<tr class="odd">
<td colspan="3">Requestor Company Name:</td>
<td colspan="15">     </td>
</tr>
<tr class="even">
<td colspan="3">Requestor Name:</td>
<td colspan="7">     </td>
<td colspan="2">Title:</td>
<td colspan="6">     </td>
</tr>
<tr class="odd">
<td colspan="18">Please identify if you are: <em>(Select all that
apply)</em> Requestor Operator Owner</td>
</tr>
<tr class="even">
<td>Company Address:</td>
<td colspan="7">     </td>
<td colspan="3">     </td>
<td colspan="3">  </td>
<td colspan="3">     </td>
<td>     </td>
</tr>
<tr class="odd">
<td></td>
<td colspan="7"><em>Street Address (No P.O. Boxes)</em></td>
<td colspan="3"><em>City/Province</em></td>
<td colspan="3"><em>State</em></td>
<td colspan="3"><em>Country</em></td>
<td><em>Postal/Zip Code</em></td>
</tr>
<tr class="even">
<td>Phone No:</td>
<td colspan="4">(     )     -     </td>
<td colspan="8">Emergency/24-hour Contact Information:</td>
<td colspan="5">     </td>
</tr>
<tr class="odd">
<td>Fax No:</td>
<td colspan="4">(     )     -     </td>
<td colspan="8">Email:</td>
<td colspan="5">     </td>
</tr>
<tr class="even">
<td colspan="18"></td>
</tr>
<tr class="odd">
<td colspan="18"><strong>Section II. Aircraft Operator/Owner
Information</strong> <em>(Complete only if different from
above)</em></td>
</tr>
<tr class="even">
<td colspan="3"><em><strong>Operator</strong></em> Company Name:</td>
<td colspan="15">     </td>
</tr>
<tr class="odd">
<td colspan="3">Operator Name:</td>
<td colspan="15">     </td>
</tr>
<tr class="even">
<td>Address:</td>
<td colspan="7">     </td>
<td colspan="3">     </td>
<td colspan="3">  </td>
<td colspan="2">     </td>
<td colspan="2">     </td>
</tr>
<tr class="odd">
<td></td>
<td colspan="7"><em>Street Address (No P.O. Boxes)</em></td>
<td colspan="3"><em>City/Province</em></td>
<td colspan="3"><em>State</em></td>
<td colspan="2"><em>Country</em></td>
<td colspan="2"><em>Postal/Zip Code</em></td>
</tr>
<tr class="even">
<td>Phone No:</td>
<td colspan="4">(     )     -     </td>
<td colspan="8">Emergency/24-hour Contact Information:</td>
<td colspan="5">     </td>
</tr>
<tr class="odd">
<td>Fax No:</td>
<td colspan="4">(     )     -     </td>
<td colspan="8">Email:</td>
<td colspan="5">     </td>
</tr>
<tr class="even">
<td colspan="3"><p><em><strong>Owner</strong></em></p>
<p>Company Name:</p></td>
<td colspan="15">     </td>
</tr>
<tr class="odd">
<td colspan="3">Owner Name:</td>
<td colspan="15">     </td>
</tr>
<tr class="even">
<td>Address:</td>
<td colspan="7">     </td>
<td colspan="3">     </td>
<td colspan="3">  </td>
<td colspan="2">     </td>
<td colspan="2">     </td>
</tr>
<tr class="odd">
<td></td>
<td colspan="7"><em>Street Address (No P.O. Boxes)</em></td>
<td colspan="3"><em>City/Province</em></td>
<td colspan="3"><em>State</em></td>
<td colspan="2"><em>Country</em></td>
<td colspan="2"><em>Postal/Zip Code</em></td>
</tr>
<tr class="even">
<td>Phone No:</td>
<td colspan="4">(     )     -     </td>
<td colspan="8">Emergency/24-hour Contact Information:</td>
<td colspan="5">     </td>
</tr>
<tr class="odd">
<td>Fax No:</td>
<td colspan="4">(     )     -     </td>
<td colspan="8">Email:</td>
<td colspan="5">     </td>
</tr>
<tr class="even">
<td colspan="18"></td>
</tr>
<tr class="odd">
<td colspan="18"><strong>Section III. Aircraft Information</strong></td>
</tr>
<tr class="even">
<td colspan="2">Type/Model:</td>
<td colspan="5">     </td>
<td colspan="8">Call Sign:</td>
<td colspan="3">     </td>
</tr>
<tr class="odd">
<td colspan="2">Tail Number:</td>
<td colspan="5">     </td>
<td colspan="8">Max. Certified Takeoff Gross Wt.:</td>
<td colspan="3">     </td>
</tr>
<tr class="even">
<td colspan="4">Country of Aircraft Registration:</td>
<td colspan="14">     </td>
</tr>
<tr class="odd">
<td colspan="18"></td>
</tr>
</tbody>
</table>

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<col style="width: 3%" />
<col style="width: 14%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="15"><strong>Section IV. Pilot, Crew, and Passenger
Information:</strong> Select your passenger type and complete the fields
for each passenger per column. For Place of Birth (POB): If U.S., list
City and State; If outside the U.S., list City/Province and Country. Use
attachments as necessary.</td>
</tr>
<tr class="even">
<td colspan="2" rowspan="2"></td>
<td colspan="2"><strong>A.</strong></td>
<td colspan="3"><strong>B.</strong></td>
<td colspan="3"><strong>C.</strong></td>
<td><strong>D.</strong></td>
<td colspan="3"><strong>E.</strong></td>
<td><strong>F.</strong></td>
</tr>
<tr class="odd">
<td colspan="2"><p> Pilot</p>
<p> Crew</p>
<p> Passenger</p></td>
<td colspan="3"><p> Pilot</p>
<p> Crew</p>
<p> Passenger</p></td>
<td colspan="3"><p> Pilot</p>
<p> Crew</p>
<p> Passenger</p></td>
<td><p> Pilot</p>
<p> Crew</p>
<p> Passenger</p></td>
<td colspan="3"><p> Pilot</p>
<p> Crew</p>
<p> Passenger</p></td>
<td><p> Pilot</p>
<p> Crew</p>
<p> Passenger</p></td>
</tr>
<tr class="even">
<td colspan="2"><strong>Last Name</strong></td>
<td colspan="2">     </td>
<td colspan="3">     </td>
<td colspan="3">     </td>
<td>     </td>
<td colspan="3">     </td>
<td>     </td>
</tr>
<tr class="odd">
<td colspan="2"><strong>First Name</strong></td>
<td colspan="2">     </td>
<td colspan="3">     </td>
<td colspan="3">     </td>
<td>     </td>
<td colspan="3">     </td>
<td>     </td>
</tr>
<tr class="even">
<td colspan="2"><strong>MI</strong></td>
<td colspan="2">  </td>
<td colspan="3">  </td>
<td colspan="3">  </td>
<td>  </td>
<td colspan="3">  </td>
<td>  </td>
</tr>
<tr class="odd">
<td colspan="2"><strong>Date of Birth (mm/dd/yyyy)</strong></td>
<td colspan="2">   /    /     </td>
<td colspan="3">   /    /     </td>
<td colspan="3">   /    /     </td>
<td>   /    /     </td>
<td colspan="3">   /    /     </td>
<td>   /    /     </td>
</tr>
<tr class="even">
<td colspan="2"><strong>Place of Birth</strong></td>
<td colspan="2">     </td>
<td colspan="3">     </td>
<td colspan="3">     </td>
<td>     </td>
<td colspan="3">     </td>
<td>     </td>
</tr>
<tr class="odd">
<td colspan="2"><strong>Passport Number</strong></td>
<td colspan="2">     </td>
<td colspan="3">     </td>
<td colspan="3">     </td>
<td>     </td>
<td colspan="3">     </td>
<td>     </td>
</tr>
<tr class="even">
<td colspan="2"><strong>Country of Issuance</strong></td>
<td colspan="2">     </td>
<td colspan="3">     </td>
<td colspan="3">     </td>
<td>     </td>
<td colspan="3">     </td>
<td>     </td>
</tr>
<tr class="odd">
<td colspan="2"><strong>SSN</strong></td>
<td colspan="2">    -    -     </td>
<td colspan="3">    -    -     </td>
<td colspan="3">    -    -     </td>
<td>    -    -     </td>
<td colspan="3">    -    -     </td>
<td>    -    -     </td>
</tr>
<tr class="even">
<td colspan="15"><strong>Section V. Flight Information</strong></td>
</tr>
<tr class="odd">
<td colspan="15">Request will not be processed if appropriate dates are
not provided. If only one date is provided the waiver letter will be
issued for the <u>one day</u> only. Back-dated waivers will not be
processed.</td>
</tr>
<tr class="even">
<td colspan="15"><p><u>When answering the questions below, use the 4
letter identifiers/ICAO codes only</u>.</p>
<p>List all legs of flight below. (<em>Example:
KMIA-LFPB-KMIA</em>)</p></td>
</tr>
<tr class="odd">
<td colspan="9">Radial Distance from the DCA VOR including nautical
miles:</td>
<td colspan="6">     </td>
</tr>
<tr class="even">
<td colspan="15"><em>(Example: DCA 270 @ 8.5NM)</em></td>
</tr>
<tr class="odd">
<td colspan="5">Start Date: <u>   /    /</u> <u>    </u></td>
<td colspan="10"><blockquote>
<p>End Date: <u>   /    /     </u></p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="3">Departure Point:</td>
<td colspan="12">     </td>
</tr>
<tr class="odd">
<td colspan="3">Intermediate Stops:</td>
<td colspan="12">     </td>
</tr>
<tr class="even">
<td colspan="3">Final Destination:</td>
<td colspan="12">     </td>
</tr>
<tr class="odd">
<td colspan="15"><strong>Destination Contact Information:</strong></td>
</tr>
<tr class="even">
<td>Name:</td>
<td colspan="14">     </td>
</tr>
<tr class="odd">
<td>Address:</td>
<td colspan="7">     </td>
<td colspan="4">     </td>
<td>  </td>
<td colspan="2">     </td>
</tr>
<tr class="even">
<td></td>
<td colspan="7"><em>Street Address (No P.O. Boxes)</em></td>
<td colspan="4"><em>City</em></td>
<td><em>State</em></td>
<td colspan="2"><em>Postal/Zip Code</em></td>
</tr>
<tr class="odd">
<td colspan="2">Phone No:</td>
<td colspan="4">(     )     -     </td>
<td colspan="6">Emergency/24-hour Contact Information:</td>
<td colspan="3">     </td>
</tr>
<tr class="even">
<td colspan="2">Fax No:</td>
<td colspan="4">(     )     -     </td>
<td colspan="6">Email:</td>
<td colspan="3">     </td>
</tr>
<tr class="odd">
<td colspan="15"></td>
</tr>
<tr class="even">
<td colspan="15">Purpose of Flight: FORMTEXT      </td>
</tr>
</tbody>
</table>

+-------------------------+---+------------------------+----------------+
| **VI. Security          |   |                        |                |
| Requirements**          |   |                        |                |
+-------------------------+---+------------------------+----------------+
| By submitting this      |   |                        |                |
| request, the Requestor  |   |                        |                |
| and the aircraft        |   |                        |                |
| operator (if different  |   |                        |                |
| from the Requestor)     |   |                        |                |
| agree to the following  |   |                        |                |
| requirements if TSA     |   |                        |                |
| grants the requested    |   |                        |                |
| waiver:                 |   |                        |                |
|                         |   |                        |                |
| -   The aircraft        |   |                        |                |
|     operator will       |   |                        |                |
|     verify the identity |   |                        |                |
|     of each individual  |   |                        |                |
|     boarding the        |   |                        |                |
|     aircraft for each   |   |                        |                |
|     flight leg listed   |   |                        |                |
|     in section V.       |   |                        |                |
|                         |   |                        |                |
| -   The aircraft        |   |                        |                |
|     operator will       |   |                        |                |
|     ensure that only    |   |                        |                |
|     individuals whose   |   |                        |                |
|     identifying         |   |                        |                |
|     information is      |   |                        |                |
|     included in section |   |                        |                |
|     IV of this form are |   |                        |                |
|     onboard the         |   |                        |                |
|     aircraft for any    |   |                        |                |
|     flight leg listed   |   |                        |                |
|     in section V.       |   |                        |                |
|                         |   |                        |                |
| -   The aircraft        |   |                        |                |
|     operator will not   |   |                        |                |
|     deviate from the    |   |                        |                |
|     approved air        |   |                        |                |
|     traffic flight      |   |                        |                |
|     plan.               |   |                        |                |
|                         |   |                        |                |
| -   The aircraft        |   |                        |                |
|     operator will       |   |                        |                |
|     control access to   |   |                        |                |
|     the aircraft and    |   |                        |                |
|     will search the     |   |                        |                |
|     aircraft (including |   |                        |                |
|     cargo and cabin     |   |                        |                |
|     areas) prior to     |   |                        |                |
|     each flight leg     |   |                        |                |
|     listed in section V |   |                        |                |
|     to ensure that no   |   |                        |                |
|     unusual objects,    |   |                        |                |
|     explosives, or      |   |                        |                |
|     weapons have been   |   |                        |                |
|     placed onboard.     |   |                        |                |
|                         |   |                        |                |
| Failure to comply with  |   |                        |                |
| these requirements may  |   |                        |                |
| result in the denial or |   |                        |                |
| revocation of the       |   |                        |                |
| waiver and the          |   |                        |                |
| imposition of civil     |   |                        |                |
| money penalties.        |   |                        |                |
+-------------------------+---+------------------------+----------------+
| Do not provide any      |   |                        |                |
| sensitive security      |   |                        |                |
| information when        |   |                        |                |
| answering the following |   |                        |                |
| questions.              |   |                        |                |
+-------------------------+---+------------------------+----------------+
| 1.  How is the aircraft |   |                        |                |
|     secured when not    |   |                        |                |
|     operational at the  |   |                        |                |
|     place of origin?    |   |                        |                |
|                         |   |                        |                |
| *(Locked hanger, fenced |   |                        |                |
| area with gate access,  |   |                        |                |
| security guards, etc.)* |   |                        |                |
|                         |   |                        |                |
|                         |   |                        |                |
+-------------------------+---+------------------------+----------------+
| 2\. How are the persons |   |                        |                |
| in section IV           |   |                        |                |
| positively identified   |   |                        |                |
| before boarding the     |   |                        |                |
| aircraft?               |   |                        |                |
|                         |   |                        |                |
|                         |   |                        |                |
+-------------------------+---+------------------------+----------------+
| 3\. Provide additional  |   |                        |                |
| security measures       |   |                        |                |
| taken, if any.          |   |                        |                |
|                         |   |                        |                |
|                         |   |                        |                |
+-------------------------+---+------------------------+----------------+
| **VII. Affirmation      |   |                        |                |
| Under Penalty of        |   |                        |                |
| Perjury**               |   |                        |                |
+-------------------------+---+------------------------+----------------+
| **I, hereby affirm,     |   |                        |                |
| under penalty of        |   |                        |                |
| perjury, that:**        |   |                        |                |
|                         |   |                        |                |
| The information I have  |   |                        |                |
| provided on this        |   |                        |                |
| application is true,    |   |                        |                |
| complete, and correct   |   |                        |                |
| to the best of my       |   |                        |                |
| knowledge and belief    |   |                        |                |
| and is provided in good |   |                        |                |
| faith. I understand     |   |                        |                |
| that a knowing and      |   |                        |                |
| willful false           |   |                        |                |
| statement, or an        |   |                        |                |
| omission of a material  |   |                        |                |
| fact, on this           |   |                        |                |
| application may be      |   |                        |                |
| punished by fine or     |   |                        |                |
| imprisonment or both    |   |                        |                |
| (*see* section 1001 of  |   |                        |                |
| Title 18 United States  |   |                        |                |
| Code), and may be       |   |                        |                |
| grounds for denial of a |   |                        |                |
| waiver request or       |   |                        |                |
| suspension or           |   |                        |                |
| revocation of a waiver  |   |                        |                |
| and other penalties.    |   |                        |                |
+-------------------------+---+------------------------+----------------+
| **     **               |   | **     **              |                |
+-------------------------+---+------------------------+----------------+
| *Printed Name*          |   | *Title*                |                |
+-------------------------+---+------------------------+----------------+
|                         |   |    /    /              |                |
+-------------------------+---+------------------------+----------------+
| *Signature*             |   | *Date*                 |                |
+-------------------------+---+------------------------+----------------+

**[PRIVACY STATEMENT ACT]{.underline}: Authority:** 49 U.S.C. §
40103(b)(3) and 49 U.S.C. § 114(f). **Purpose:** This information
primarily will be used to conduct background checks on crewmembers and
passengers on flights for which waivers of flight restrictions have been
sought from the FAA. **Routine Uses:** This information may be provided
to third parties, including government contractors and other
governmental agencies, as necessary to conduct the background checks. It
also may be provided to governmental agencies when relevant for criminal
and civil investigations concerning threats to civil aviation security
or violations of law, rule or regulations or for routine uses identified
in TSA system of records, DHS/TSA 002, Transportation Security Threat
Assessment System (T-STAS). **Disclosure:** You are not required to
provide this information; however, failure to do so may result in a
denial of the waiver request for the flight, or denial of permission for
you to board a flight for which a waiver has been granted. Failure to
furnish your SSN may result in delays in issuing you a waiver.

**[PAPERWORK REDUCTION ACT BURDEN STATEMENT]{.underline}:** Through this
information collection, TSA is gathering information about you to
facilitate your application for a flight waiver.  This is a mandatory
collection of information if you wish to obtain a flight waiver over
restricted airspace. It is estimated that the total average burden per
response associated with this collection can take up to 2 hours per
international request and 45 minutes per domestic request.  An agency
may not conduct or sponsor, and a person is not required to respond to,
a collection of information unless it displays a valid OMB control
number.  The control number assigned to this collection is OMB
1652-0033, which expires 9/30/2008.