UNITt;D S'l"A'fES OF AMERICA

JlEPARTMENT OF TRANSPORTA nON

OFFICE OF TIm S"~CRETARY

OFnc •~• 01'"AVIATION Al~.-\LYSIS

TITLE Vi ASSURAl~CE

(Implementing Title VI oftlleChilRigbt5 An -of 1964, 1IS~)

ASSURANCE CONCERNING ~Ol'l4])ISCRI~UNATION ON THE

BASIS OJ<'nlSA BILITY IN FEDERAJ..-LY-ASSISTED PROGIL\,.\-tS

AND ACTIVITIES RECRIVING OR BENEFITING FROM

:n·:nl<:RAL FlNA1~CIAL ASSISTANCE

(Implementing the Rehabilitation Act of 1913, as amended, and the

AirCarrier Access Ad of19S6)

49 CFR Parts 21 and 21 and 14 CFR Parts 271, and 382

tp f' ,1·

lJo·)'I -'{l'e. . rn r ... ~'- . (the Recipient) HEREBY AGREES THAT,

~--(N-'a-m-e-di Recipient)------

I. As a condition 10 receiving any Federal financial assistanc ."C . from the

Dcpartmenr of Transportation.It win comply: witb Title VI of the Civil Rights A~ of 1964.

as sll1enderl.42 US;c. 2000d--42use 2000d-4:all requirements imposed by or pursuant

\(); Title 49, Code of Federal Regulations, Part 21. Nondiscrimination in Federally-Assisted

.Programs of the Department of Tmnsportation- Effectuation of Title VI of the Ci\·il Rights

Act of It)(H~and other pertinent directives so that no person in the United Slates shan. on the

grounds of race, color, or national origin, be excluded fn:)nl panicipation in. be denied the

benefits of, or be otherwise subjected to discrimination under any program or acthilY for

which the Recipienr receives federal financial assistance from the Departmem of

Transportation. This assurance is required hy Title 49. ewe of Federal Regulations. section

2L7(a) and Title 14. Code of Federal Regulations, section 271.9(c).

II, As a condition to receiving any federal financial assistance from the

Department of' l'ransportatioa, it will comply with; section 504-of the RehabiHtmion Act of

1973, as amended (29 U.s.C 794):the Air Carrier Access Act of 1986 (49 U-<:LC.J374(c});

. and aU requiremears imposed by or pursuant (0 Title 49, Code of federal Regulations, Part

Tl.l\ondiscrimination on the Basis of Handicap in Programs and Activities Receiving or

Benefitting from Federal Finaacial Assistance, Tille 14, Code of Federal Regulations. Part

3S2, Nondiscrimination on the Basis of Handicap in Air Travel; and other pertinent directives
so that no otherwise qualified person with a disability. be excluded from participation in. be

denied thebenefits of. be discriminated against by reason of such handicap in the provision

of air transportation, or otherwise be subjected [0 discrimination under ~UI)program for

which the Recipient receives Federal financial assistance from the Department of

Transportation. This assurance is required by Tille 49. Code of Federal Regulations. section

27.9 and Title 14. Code of Federal Rcgulauons, sections 271.9(c) and 382.9.

m, 11will promptly take any rneaures necessary to effectuate this agreement. The

Recipient further agrees that it shall take reasonable actions to guarantee that it. its

contractors and subcontractors subject to the Department of Transportation regulations cited

above, transferees, and successors in interest will comply with all requirements imposed or

pursuant to the statutes and Department of Transportation regulations cited above, other

pertinent directives. and the above assurances.

IV. These assurances obligate the Recipient for [ill: period during which Federal

financialassistance is extended. The Recipient agrees that the United States has a right [0

seek judicial enforcement with regard to any matter arising under the statutes and Department

of Transportation regulations cited above. other pertinent directives, and the above

assurances.

V. Theseassurances arc given for the purpose of obtaining federal subsidy

under the Essential Air Service Program and are binding OJ} [he Recipient, contractors.

subcontractors. transferees, successors in interest. and all other participants receiving Federal

subsidy in the Essential Air Service Program, The person or persons whose signatures

appear below are authorized to sign this agreement on behalf of the Recipient.

VI. In addition [0 these assurances. the Recipient agrees ro file: a summary of all

complaints filed against it within the pHS! year that allege violatioms) by the Recipient of

Title VI of the Civil Right'> Act of I%4, as amended, section 504 of the Rehabilitation Act of

1973. as amended. or the Air Carrier Access Act of 1986; or a statement [hat there have been

no complaints filed against it The summary should include the date the complaint was tiled,

the nature of the complaint. rhe status or outcome of the complaint <1.&:. whether it is still

pending or how it was resolved).

By:
UNITED STATES OF AMERICA

DEPARTMENT OF TRANSPORTATION

OJi')!'ICEOF THE SECRETARY

Ol,'fleE OF AVlATlON ANALYSIS·

CERTIFICATION RE(~ARDING DRUG-FREE WORKPLACE REQUIREMENTS

IN THE PERFORMANCE OF SUBSIDIZED ESSEl'{IIAI ..AIR SERVICE

A_. The subsidized essential air service carrier certifies that it will. or will continue, to provide a drugfree workplace by;

(a) Publishing a statement notifying employees that the unlawful manufacture, distribution,

dispensing. possession or useof a controlled substance is prohibited in the carrier'sworkplace, and

specifying the actions that will be tuk(:" against employees for violation of such prohibition:

(b) Establishing an ongoing drug-free awareness program to inform employees about-

(1) The dangers of drug abuse in the workplace;

(2) The grantee's policy of maintaining a drug-free workplace;

(31 Any available drugcounseltng.rehabilitation.nnd employee.assistanceprograms; and

(4) The penalties that ma)' he imposed upon employees for drug abuse violations

occurring in the workplace;

(c) Making it a requirement that each employee to be engaged in Ute performance of work

supported by the subsidy be given a copy of the statement required by paragraph (a);

(d) l\'otifying the employee in the statement required by paragraph (a) that, as-a condition of

employment supported by thesubsidy, the employee wiU--

(1) Abide by the terms of Ihe statement; and

(2) Notify the employer in writing of his or ber conviction for a violation of a t.:rintinal

drug statute occurring in the workplace no later than five calendar days after such

conviction:

(el Notifying the agency in writing, within [ell calendar days after receiving notice onder

paragraph (d)(2) from an employee or otherwise receiving actual notice of convicnon,

Employers of convicted employees. must provide notice. including position title, to the

Office of Aviation Analysis. Notice shalt include the order number of each affected

subsidized service;

(t) Taking one of the Iollowing action.". within 30 days of receiving notice under paragraph

{d)(2), with respect to any employee who is so convicted-

(I) Taking appropriate personnel action against such an employee, up to and including

termination, consistent with the requirements of the Rehabilitation Act of 1973,.3s

amended,or

(2) Requiring such employee to participate satisfactorily in a drug abuse assistance or

rclliiNlit..1tion program approved for such purposes by a Federal, Slate or local

health, law enforcement, or other appropriate agency;
(g) Malcing a good faith effort to continue (0 maintain a drug-free workplace through

implementation of paragraphs (a), (b). (e). (d). (e) and (f).

B. The subsidized essential air service carrier may. but is not required to. insert in the space provided

below the site for the performance of work done in connection with the specific grant.

Places of Performance (street address, city, COUll I)' •state. zip code). For the provision of essential air

service, workplaces include outstations. maintenance sites, headquarters office locations. training sites

and any other worksites where work is performed that is.supported by [he subsidy.

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Check f 1 if (here arc workplaces on file lhat arc not identified here.

-~--
UNITE)) STAI ES OF AMERICA

DRPARTMENT OF TRANSPORTATION

OFFICE OF THE SECRETARY

OFFlCE OF AVIATION .<\'~ALYSIS

CERTIFICATION REGARDI_ G INFLUENCING ACTIVITIES

Certification for Contracts, Grants, Loans,

and Cooperative Agreements

The undersigned certifies. [0 the best of his or her knowledge and belief, that:

(I) No Federal appropriated funds have been paid or will be paid. b~ Or on behalf of the

undersigned, to any person for influencing or auernpting to influence an officer or employee

of any agency. a Member of Congress. an officer or employee of Congress, or an employee

of a Member of Congress. in connection with the awarding of any Federal contract. {]lC

making of any Federal grant. the making of any Federal loan. the entering into of any

coopcrati c agreement. and the extension. continuation. renewal. amendment. or

modification of any Federal contract. grant, loan. or cooperative agreement,

(2) If any funds other than federal appropriated funds have been paid \.11' will be paid to any

person for influencing or attempting to influence an officer or employee of any agency. a

Member of Congress. an officer or employee of Congress. or an employee of a Member of

Congress in connection with this federal contract, grant, loan. or cooperative agreement. the

undersigned shall complete and submil Standard Form-LLL, "Disclosure form to Report

Influencing Activities," in accordance with its instructions.

(3) The undersigned shall require that the language of this certification be included in the

award documents for all subawards at all tiers {including subcontracts, subgrants. emu

contract" under grants. loans and cooperative agreements) and that all subrecipients shall

certify (met disclose accordingly.

This certification is a material representation of fact upon which reliance was placed when

this transaction was made or entered into. Submission of this certification is a prerequisite

for making or entering into this transaction imposed by section 1352. title 31. U,S. Code.

Any person who fails to file the required certification shall he subject LO a civil penalty of not

less than SJO.OOOand nul more than $IOOJXX) for each such failure,

~

Signature

Title

CVN - 'DFL"

essential Air Service Poinns) To Which Certification Applies
---- "----- _._-----------

INSTRUCTIONS FOR CERTIFICATION

l, By signing and/or submitting this application or grant agreement. the subsidized essential air service

carrier is providing the certiflcaiion.

2. The certification is a material representation of fact upon which reliance is placed when (he agency

awards the subsidy, If it is later determined that the subsidized carrier knowingly rendered a false .

certification. or otherwise violated {he requirements of the Drug Free Workplace Act, the agency. in

addition to any other remedies available-to the federal Government •.may takeaetlon authorized under

tbe Drug-Free Workplace Act.

3. Wofkplac~ under grants, for grantees other than individeals, need not be identified on the

cenitication. If known. the}' may be identified in the subsidy application. If the subsidized carrier docs

not idemify [he workplaces at the time of application, or upon award if rhere is no application, the.

carrier must keep t.hc identity of the workplaces on file in its office and make the info.rmationavailable

for Federal Inspection. Failure to identif), all known workplaces constitutes- a violation of the

subsidized carrier's drug-free workplace requirements.

4. Workplace identifications must include tbc actual address of buildings (or parts of buildings) or

othersites where work under the grant take!'; place. Categorical descriptions may be used (c.g .•all

counters at the airports served by the carrier).

5. Ifthc workplace identified to th~ agency changes during the performance of (he subsidized service,

tile subsidized carrier shall inform tile agency of the Change. if it previously i&:nti1ied the workplace in

question. .

6.. Definitions of terms in the Nonprocuremcnl Suspension and Debarment common rule (49 CFR Part

29) and Drug-Free Workplace common rule (49 Cf-R Part 29. Subpart F) apply to this certification.

Carriers' auennon is called. in particular. to the following definitions from these rules:

ControUed substance means a controlled substance in Schedules I through V of the Controlled

Substances Act (21 use 812) and as further defined by regulation (21 eFR 1308.1) through 1308.15):

Conviction means a finding of guilE (including a plea of nolo contenderes or imposition of sentence, or

both, by any judicial body charged with the responsibility to determine violations of the Federal or

Stale. criminal drug statutes;

Criminal dr~g statute means a Federal or non federal criminal statute involving the manufacture.

distribution. dispensing. use, or possession of any controlled substance:

Employee means the employeeof a subsidized carrierdirectly engaged in the performance of work

supported by ~ subsidy. including: en AU direct charge employees; (ii) AU indirect charge

employees unless their impact or involvement is insignificant to theperformance of subsidi7.ed service;

and (iii) Temporary.personnel and consultants who are directly engaged in the performance of work

supported by the subsidy and who are on the subsidized carrier's payroll. This deflnaiondoes not

include workers not on the payron of the subsidized carrier (e.g •• volunteers, even if used to meet a

marching requirement; eonsuhanrs or independent conuactcrs not on rhe subsidized carrier's payroll; or

cmptoy~esofsubrecipients or subcontractors in covered workplaces).