Please review each of the following attestation statements below carefully. FAA BasicMed requires that you acknowledge and agree to each of these before completing the course content.

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 FAASafety.gov 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

(required)

Address Line 2

City

Zip Code

Pilot Phone Number

Pilot Certificate Number

Password

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

Submit My Information
BasicMed Paperwork Reduction Act Notice

The information collection is conducted in accordance with the requirements of 44 USC § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. The information collected on this form is necessary to determine eligibility to exercise pilot privileges under BasicMed and is consistent with the FAA’s authority to regulate and promote safety in air commerce under 49 USC 44701; see also the Federal Aviation Administration Extension, Safety, and Security Act of 2016, Pub. L. 114-190 § 2307, Medical Certification of Certain Small Aircraft Pilots. When all requirements have been met, an entry will be made in the airman’s record noting BasicMed course completion. The FAA estimated that it will take each user .5 hours per user to complete the BasicMed Comprehensive Medical Examination Checklist, and 0.75 hours per user to complete the online training, certification, and consent. The information is required to be eligible to exercise pilot privileges under BasicMed and will become part of the Privacy Act system of records DOT/FAA 847, General Air Transportation Records on Individuals. Note that an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The control number for this collection of information is 2120-0770.