Unmanned Aircraft System (UAS) Request and Privacy Practices Agreement

University Police
Contact: Emergency Manager

This form must be completed and submitted to the SUNY Brockport University Police Department for UAS Committee review as it relates to the use of UAS Operations on campus, until further notice. See the Unmanned Aircraft System (UAS) Policy

Submission Deadlines:
Outdoor flight request - Fourteen (14) business days PRIOR TO operation.
Indoor flight request - Twenty-one (21) business days PRIOR TO operation.
Requestor Name Requestor Name First Last
Requesting Department
You selected "Other Non-Brockport Entity". Please identify:
Requestor Email
Requestor Phone Requestor Phone - ### - ### ####
Indicate whether requestor is

Indicate whether requestor is Different from Remote Pilot Also the Remote Pilot
FYI: Non-University business operators and non-student recreational operators must additionally apply to the campus and receive a revocable permit in compliance with the SUNY Use of Facilities by Non-Commercial Organizations Policy or the SUNY Brockport Commercial Enterprise Policy, as applicable.
Remote Pilot Name Remote Pilot Name First Last
Remote Pilot Email
Phone Phone - ### - ### ####
FAA Remote Pilot Certificate Number
UAS Details
UAS Make and Model
UAS FAA Registration Number
Flight Request is for (select all that apply)

Flight Request is for (select all that apply) Indoor Outdoor
Indoor building location
Room Number/Name
Outdoor location
Confirm if requesting department is
Is UAS operation part of a University credit course?

Is UAS operation part of a University credit course? Yes No
Is UAS operation associated with a University-sponsored activity?

Is UAS operation associated with a University-sponsored activity? No Yes, explain: Yes, explain:
Flight Narrative (Purpose of the flight, i.e. recreational use, registered student organization, non-University business operation, etc.):
Flight Duration (dates, times, etc.)

Indoor requests must be made at least twenty-one (21) business days in advance of operation.
Will photos/video be captured?

Will photos/video be captured? Yes No
Upload copy of the Certificate of Insurance
maximum 5 files whose total size may not be more than 10MB
filenames should not contain more than one period (.)
Upload copy of the Remote Pilot Certificate
maximum 5 files whose total size may not be more than 10MB
filenames should not contain more than one period (.)
*Please upload any other significant or important information (such as revocable permit, if applies) to share with University Police*
maximum 5 files whose total size may not be more than 10MB
filenames should not contain more than one period (.)
ASSURANCES

• I have read and will abide by all applicable FAA policies and procedures while conducting UAS operations.
• I will secure all necessary approvals prior to conducting UAS operations.
• I have secured and provided supporting documentation to the SUNY Brockport University Police regarding Indemnification and Liability Insurance.
• When approval is granted, I will conduct thorough pre-flight check prior to each flight and will make note of any modification need to UAS prior to flight.
• I will fly in a manner that does not cause or create undue hazards to persons or property.
• I will not take photographs, videos, or monitor areas of the University where members of the SUNY Brockport community would have a reasonable expectation of privacy such as; outside windows or doorways, if indoors - locker rooms, restrooms, individual residence rooms, or other private area;
• In the case of an incident causing serious injury or harm to personnel and or damage to property other than the UAS itself, I will immediately notify SUNY Brockport University Police Department and provide a detailed and accurate description of what occurred. I understand I am responsible for any damages/injuries occurring to University property or individuals result from any negligent act or misconduct during this operation.
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date of signature Date of signature / MM / DD YYYY

Unmanned Aircraft System (UAS) Request and Privacy Practices Agreement

FYI: Non-University business operators and non-student recreational operators must additionally apply to the campus and receive a revocable permit in compliance with the SUNY Use of Facilities by Non-Commercial Organizations Policy or the SUNY Brockport Commercial Enterprise Policy, as applicable.

UAS Details