University Police and Campus Safety | UAS Request Form - University Police and Campus Safety

Section 1: Requestor Information

Applicant Full Name *

First M.I. Last

Applicant Email *

Affiliation *

University (Current University Faculty, Staff, or Student)
Commercial/Contract

Please provide proof of commercial general liability coverage with a minimum limit per occurrence of $1,000,000 and a minimum general aggregate or $2,000,000 *

UM Department or Sponsor/Organization

Mailing Address *

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Contact Phone *

107 Remote Pilot Certificate Number

Section 2: Purpose of UAS Request/Proposed Activity

Provide full details of flight purpose (education, research, promotional, etc.), including identity of UAS operator(s) and/or flight team. Depending on your intended use and activities associated with the use of your UAS, there may be other university approvals required before you can operate your UAS on university property. For example, any activities that involve Athletics also require approval by Neal Mead at nmead@OleMiss.edu. A copy of his approval must be submitted with this application. *

Specific Location of Activity *

Date(s) of UAS Activity *

Starting Time *

: HH

MM

Ending Time *

: HH

MM

Section 3: UAS Description

Type/Model of UAS *

Weight/Dimensions *

Power Source/Serial # *

Previous Request Approved *

Yes
No

Date of Previous Approval *

UAS Certificate of Registration *

Yes
No

UAS Certificate *

Photographs taken during flight *

Yes
No

Videos recorded during flight *

Yes
No

Equipped with Geo-fencing *

Yes
No

Operating under a COA/333 *

Yes
No

Upload a copy of your FAA waiver, authorization, or other relevant flight documentation for this request.

For questions or assistance, please email jtglasz@olemiss.edu or call 662-915-3242.

Signature *

Date *

By signing above, the individual/entity submitting this request agrees to and will abide by all university policies governing the use of Unmanned Aircraft Systems on or over university property or sponsored event. A copy of the approved UAS Request Form must be in possession of the operator at all times during the activity, and must be presented to any university official or representative with control or jurisdiction over the activity, upon request. The university reserves the right to request additional documentation as a condition of approval and operation. In addition, any operator violating any portion of the University Unmanned Aircraft Systems (UAS) Policy, will be held accountable for their actions.

Comments

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Unmanned Aircraft Systems (UAS) Request Form

Section 1: Requestor Information

Section 2: Purpose of UAS Request/Proposed Activity

Section 3: UAS Description