Form Approved OMB No. 2120-0033 04/30/2010 NATIONAL EXAMINER BOARD-DESIGNATED PILOT EXAMINER CANDIDATE APPLICATION Supplemental information and Instructions U.S. Department of Transportation Federal Aviation Administration Paperwork Reduction Act Statement We use this form to collect essential information concerning your professional and personal qualifications to become a designee. The FAA uses this information to screen and select the designee. We estimate that it will take about 54 minutes to complete the form. Providing the information is mandatory is you wish to apply to become a Designated Pilot Examiner. The information becomes part of the Privacy Act system of records DOT/FAA 830, Representatives of the Administrator, and is subject to the routine uses of that system as described above. Please not that an Agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it display a currently valid OMB control number. The OMB control number associated with this collection of information is 2120-0033. Comments concerning the accuracy of this burden and suggestions for reducing the burden should be directed to the FAA at: 800 Independence Ave SW, Washington, DC 20591, Attn: Information Collection Clearance Officer, ABA-20. Detach all supplemental Information and Instruction shoots before submitting application. NATIONAL EXAMINER BOARD-DESIGNATED PILOT EXAMINER CANDIDATE APPLICATION HOW TO APPLY -- (Initial Designations) Answer all applicable questions (blocks) fully. Refer to the attached instruction sheets if you require assistance to answer a question (block). Complete, sign, and date this application in black ink. If you need more space to answer a question (block), use additional sheets of blank paper. Be sure to indicate the question (block) number and your name at the top of each additional sheet. Attach a copy (front and back) of all applicable pilot, flight instructor, and airman medical certificates to this application. Remove all instruction sheets before you send in your completed application. Be sure to keep a completed copy of the application and all additional sheets for your files. WHERE TO SEND APPLICATION-Federal Aviation Administration, Designee Standardization Branch (AFS-640), ATTN: National Examiner Board, P.O. Box 25082, Oklahoma City, OK 73125-0082 WHAT HAPPENS TO YOUR APPLICATION-The National Examiner Board (NEB) will evaluate your application to ensure that you meet the selection criteria for the designation(s) sought. The NEB will advise you, in writing, whether or not you meet the applicable selection criteria. If the NEB sends you a letter stating you do not meet the selection criteria, do NOT take the predesignation knowledge test. If the NEB sends you a letter stating you do meet the selection criteria, you will be directed to take the examiner predesignation knowledge test appropriate to the designation(s) sought. For example: airplane (PEA), rotorcraft (PER), glider (PEG), and balloon (PEB). You may take the examiner predesignation knowledge test at any FAA-approved computerized testing center. Request the pilot examiner predesignation knowledge test for the category applicable to the designation(s) sought. You MUST forward the original test results to the NEB within 10 days of the date you take the examiner predesignation knowledge test. Keep a copy of the test results for your personal records. Upon receiving your original test results with a score of 80 percent or higher, the NEB will notify you of approval or disapproval for assignment to the national examiner candidate pool. The NEB will forward only die top three ranking candidates within the national examiner candidate pool to each FSDO that requests a new designee. If you are selected, you must be available to serve the entire FSDO area. The NEB keeps your application in the national examiner candidate pool for 2 years or until a FSDO selects you, whichever comes first. After 2 years, the NEB win delete the applications of all candidates not selected by a FSDO from the national examiner candidate pool. An applicant must repeat the application process in order to apply for reassignment to the national examiner candidate pool. NOTE: FAA Form 87 1 0- I 0 is used by the National Examiner Board for initial designation. FAA Form 87 1 0- I 0 does not supersede FAA Form 8710-6, Examiner Designation and Qualification Record. FAA Form 8710-6 may still be used for renewal of PPE's, ACR's, and DPE's. Request for reinstatement must go to the NEB if the applicant has moved from the original designating district office's area of responsibility. FAA Form 8710- 10 (1 -00) i NSN: 0052-00-918-0000 American LegalNet, Inc. www.FormsWorkFlow.com . . PRIVACY ACT STATEMENT: 7KLV VWDWHPHQW LV SURYLGHG SXUVXDQW WR WKH 3ULYDF\ $FW RI   86& † D 7KH DXWKRULW\ IRU FROOHFWLQJ WKLV LQIRUPDWLRQ LV FRQWDLQHG LQ  86& ††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³$YLDWLRQ 5HFRUGV RQ ,QGLYLGXDOV´ DQG ZLOO EH VXEMHFW WR WKH URX WLQH XVHV SXEOLVKHG LQ WKH 6\VWHP RI 5HFRUGV 1RWLFH 6251 IRU '27)$$  VHH ZZZGRWJRYSULYDF\SULYDF\DFWQRWLFHV LQFOXGLQJ D 3URYLGLQJ EDVLF DLUPHQ FHUWLILFDWLRQ DQG TXDOLILFDWLRQ LQIRUPDWLRQ WR WKH SXEOLF XSRQ UHTXHVW H[DPSOHV RI EDVLF LQIRUPDWLRQ LQFOXGH ‡ 7KH W\SH RI FHUWLILFDWHV DQG UDWLQJV KHOG OLPLWDWLRQV GDWH RI LVVXDQFH DQG FHUWLILFDWH QXPEHU ‡ 7KH VWDWXV RI WKH DLUPDQ¶V FHUWLILFDWH LH ZKHWKHU LW LV FXUUHQW RU KDV EHHQ DPHQGHG PRGLILHG VXVSHQGHG RU UHYRNHG IRU DQ\ UHDVRQ ‡ 7KH DLUPDQ¶V KRPH DGGUHVV XQOHVV UHTXHVWHG E\ WKH DLUPDQ WR EH ZLWKKHOG IURP SXEOLF GLVFORVXUH SHU  86& F ‡ ,QIRUPDWLRQ UHODWLQJ WR DQ DLUPDQ¶V SK\VLFDO VWDWXV RU FRQGLWLRQ XVHG WR GHWHUPLQH VWDWLVWLFDOO\ WKH YDOLGLW\ RI )$$ PHGLFDO VWDQGDUGV DQG WKH GDWH FODVV DQG UHVWULFWLRQV RI WKH ODWHVW SK\VLFDO ‡ ,QIRUPDWLRQ UHODWLQJ WR DQ LQGLYLGXDO¶V HOLJLELOLW\ IRU PHGLFDO FHUWLILFDWLRQ UHTXHVWV IRU H[HPSWLRQ IURP PHGLFDO UHTXLUHPHQWV DQG UHTXHVWV IRU UHYLHZ RI FHUWLILFDWH GHQLDOV E 8VLQJ FRQWDFW LQIRUPDWLRQ WR LQIRUP DLUPHQ RI PHHWLQJV DQG VHPLQDUV FRQGXFWHG E\ WKH )$$ UHJDUGLQJ DYLDWLRQ VDIHW\ F 'LVFORVLQJ LQIRUPDWLRQ WR WKH 1DWLRQDO 7UDQVSRUWDWLRQ 6DIHW\ %RDUG 176% LQ FRQQHFWLRQ ZLWK LWV LQYHVWLJDWLRQ UHVSRQVLELOLWLHV G 3URYLGLQJ LQIRUPDWLRQ DERXW DLUPHQ WR )HGHUDO 6WDWH ORFDO DQG WULEDO ODZ HQIRUFHPHQW DJHQFLHV ZKHQ HQJDJHG LQ DQ RIILFLDO LQYHVWLJDWLRQ LQ ZKLFK DQ DLUPDQ LV LQYROYHG H 3URYLGLQJ LQIRUPDWLRQ DERXW HQIRUFHPHQW DFWLRQV RU RUGHUV LVVXHG WKHUHXQGHU WR )HGHUDO DJHQFLHV WKH DYLDWLRQ LQGXVWU\ DQG WKH SXEOLF XSRQ UHTXHVW I 0DNLQJ UHFRUGV RI GHOLQTXHQW FLYLO SHQDOWLHV RZHG WR WKH )$$ DYDLODEOH WR WKH 86 'HSDUWPHQW RI WKH 7UHDVXU\ DQG WKH 86 'HSDUWPHQW RI -XVWLFH '2- IRU FROOHFWLRQ SXUVX DQW WR  86& J J 0DNLQJ UHFRUGV RI HIIHFWLYH RUGHUV DJDLQVW WKH FHUWLILFDWHV RI DLUPHQ DYDLODEOH WR WKHLU HPSOR\HUV LI WKH DLUPHQ XVH WKH DIIHFWHG FHUWLILFDWHV WR SHUIRUP MRE UHVSRQVLELOLWLHV IRU WKRVH HPSOR\HUV K 0DNLQJ DLUPHQ UHFRUGV DYDLODEOH WR XVHUV RI )$$¶V 6DIHW\ 3HUIRUPDQFH $QDO\VLV 6\VWHP 63$6 LQFOXGLQJ WKH 'HSDUWPHQW RI 'HIHQVH &RPPHUFLDO $LUOLIW 'LYLVLRQ¶V $LU &DU ULHU $QDO\VLV 6XSSRUW 6\VWHP $&$6 IRU LWV XVH LQ LGHQWLI\LQJ VDIHW\ KD]DUGV DQG ULVN DUHDV WDUJHWLQJ LQVSHFWLRQ HIIRUWV IRU FHUWLILFDWH KROGHUV RI JUHDWHVW ULVN DQG PRQLWRULQJ WKH HIIHFWLYHQHVV RI WDUJHWHG RYHUVLJKW DFWLRQV L 0DNLQJ UHFRUGV RI DQ LQGLYLGXDO¶V SRVLWLYH GUXJ WHVW UHVXOW DOFRKRO WHVW UHVXOW RI  RU JUHDWHU EUHDWK DOFRKRO FRQFHQWUDWLRQ RU UHIXVDO WR VXEPLW WR WHVWLQJ UHTXLUHG XQGHU D '27UHTXLUHG WHVWLQJ SURJUDP DYDLODEOH WR WKLUG SDUWLHV LQFOXGLQJ FXUUHQW DQG SURVSHFWLYH HPSOR\HUV RI VXFK LQGLYLGXDOV 6XFK UHFRUGV DOVR FRQWDLQ WKH QDPHV DQG WLWOHV RI LQGL YLGXDOV ZKR LQ WKHLU FRPPHUFLDO FDSDFLW\ DGPLQLVWHU WKH GUXJ DQG DOFRKRO WHVWLQJ SURJUDPV RI DYLDWLRQ HQWLWLHV M 3URYLGLQJ LQIRUPDWLRQ DERXW DLUPHQ WKURXJK WKH &LYLO $YLDWLRQ 5HJLVWU\¶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¶V VHFXUH HQYLURQPHQW N 0DNLQJ SHUVRQDOO\ LGHQWLILDEOH LQIRUPDWLRQ DERXW DLUPHQ DYDLODEOH WR RWKHU )HGHUDO DJHQFLHV IRU WKH SXUSRVH RI YHULI\LQJ WKH DFFXUDF\ DQG FRPSOHWHQHVV RI PHGLFDO LQIRUPDWLRQ SURYLGHG WR )$$ LQ FRQQHFWLRQ ZLWK DSSOLFDWLRQV IRU DLUPHQ PHGLFDO FHUWLILFDWLRQ O 0DNLQJ UHFRUGV RI SDVW DLUPDQ PHGLFDO FHUWLILFDWLRQ KLVWRU\ GDWD DYDLODEOH WR $YLDWLRQ 0HGLFDO ([DPLQHUV $0(V RQ D URXWLQH EDVLV VR WKDW $0(V PD\ UHQGHU WKH EHVW PHGLFDO FHUWLILFDWLRQ GHFLVLRQ P 0DNLQJ DLUPDQ DLUFUDIW DQG RSHUDWRU UHFRUG HOHPHQWV DYDLODEOH WR XVHUV RI )$$¶V 6N\ZDWFK V\VWHP LQFOXGLQJ WKH 'HSDUWPHQW RI 'HIHQVH 'R' WKH 'HSDUWPHQW RI +RPHODQG 6HFXULW\ '+6 '2- DQG RWKHU DXWKRUL]HG )HGHUDO DJHQFLHV IRU WKHLU XVH LQ PDQDJLQJ WUDFNLQJ DQG UHSRUWLQJ DYLDWLRQUHODWHG VHFXULW\ HYHQWV Q 2WKHU SRVVLEOH URXWLQH XVHV SXEOLVKHG LQ WKH )HGHUDO 5HJLVWHU VHH 3UHIDWRU\ 6WDWHPHQW RI *HQHUDO 5RXWLQH 8VHV IRU DGGLWLRQDO XVHV  )5  )RU H[DPSOH D UHFRUG IURP WKLV V\VWHP RI UHFRUGV PD\ EH GLVFORVHG WR WKH 8QLWHG 6WDWHV &RDVW *XDUG &RDVW *XDUG DQG WR WKH 7UDQVSRUWDWLRQ 6HFXULW\ $GPLQLVWUDWLRQ 76$ LI LQIRUPDWLRQ IURP WKLV V\VWHP ZDV VKDUHG ZLWK HLWKHU DJHQF\ ZKHQ WKDW DJHQF\ ZDV D FRPSRQHQW RI WKH 'HSDUWPHQW RI 7UDQVSRUWDWLRQ '27 EHIRUH LWV WUDQVIHU WR '+6 DQG VXFK GLVFORVXUH LV QHFHVVDU\ WR DFFRPSOLVK D '27 76$ RU &RDVW *XDUG IXQFWLRQ UHODWHG WR WKLV V\VWHP RI UHFRUGV American LegalNet, Inc. www.FormsWorkFlow.com Form Approved OMB No. 2120-0033 04/30/2010 NATIONAL EXAMINER BOARD—DESIGNATED PILOT EXAMINER CANDIDATE APPLICATION — Supplemental Information and Instructions (Continued) TYPES OF DESIGNATIONS AND DESIGNEE DEFINITIONS— — PE - Private Pilot Examiner CIRE - Commercial and Instrument Rating Pilot Examiner - Commercial Pilot Examiner (For rotorcraft, gliders, and/or lighter-than-air aircraft only.) CE ATPE - Airline Transport Pilot Examiner GENERAL QUALIFICATIONS— — • The applicant must hold all pertinent category, class, and type ratings for each aircraft for which designation is sought. • For a designation requiring a medical certificate, the applicant must hold a valid third-class airman medical certificate for initial designation. (A medical certificate is NOT required for designations limited to examining in balloons and gliders.) • The applicant must be at least 21 years old. • The applicant must have a good record as a pilot and flight instructor with regard to accidents, incidents, and violations. • The applicant must meet all eligibility and experience requirements for the specific designation sought in accordance with the tables beginning on page iv for PE, CE, CIRE, ATPE requirements, the appropriate FAA order, handbooks, and pertinent, current Flight Standards Handbook Bulletin for General Aviation. • The applicant must have a reputation for integrity and dependability in the industry and the community. • The applicant must have a history of a harmonious relationship with the FAA. INSTRUCTIONS FOR COMPLETING FAA FORM 8710-10— — 1. All entries on FAA Form 8710-10 must be made in black ink or typewritten. 2. Read the attached "Privacy Act Statement." 3. Complete blocks 1 through 33: a. Block 1. Name (Last, First, Middle)— (1) Enter your legal name. For record purposes, do not use more than one middle name. (2) If you do not have a middle name, enter "NMN" (no middle name) or "NMI" (no middle initial). (3) If you have initial(s) only, enter the initials and then enter "INITIALS ONLY." (4) If you are a junior, III, IV, etc., so indicate. b. Block 2. Social Security Number— (1) Completing Block 2 is optional (see "Privacy Act Statement"). (2) Enter your Social Security Number or one of the following: "DO NOT USE" or "NONE." c. Block 2A. Date of Birth—Enter date using eight-digit, numeric characters (e.g., 08/09/1960 not August 9, 1960). d. Block 3. Permanent Mailing Address—Enter all required information, to include number and street, P.O. Box, City, State, and Zip Code. e. Block 4. Telephone Number—Enter your home and business telephone numbers including the area code and extensions, if applicable. You may also enter your Fax number, if applicable. f. Block 5. This application is for:—Initial Application for NEB, Renewal Application for NEB, or Reinstatement (other than initial designating FSDO) for NEB. Check the box to the left of the reason for this application. NOTE: Reinstatements are NOT to be sent to the NEB unless the applicant has moved to a different district. g. Block 6. Have you ever held an FAA pilot examiner designation in any region?—(If "YES," enter the date(s) and the supervising FSDO.) h. Block 7. Type of designation(s) sought:—Check the box to the left of the designation(s) sought. Private Pilot Examiner (PE), Commercial Pilot Examiner (CE), Airline Transport Pilot Examiner (ATPE), and Commercial Instrument Rating Examiner (CIRE). (See the SPECIFIC ELIGIBILITY REQUIREMENTS criteria shown on pages iv and v.) i. Block 8. Enter the categories, classes, and types of aircraft for which authorization is sought.—Self-explanatory. j. Block 9. Enter the FSDO that has jurisdiction in the area where you desire to serve.—Self-explanatory. k. Block 10. Enter the names of other FSDO's in whose areas you can provide examiner service on a regular basis, if any.—Selfexplanatory. l. Block 11. Has any certificate or rating issued to you ever been revoked?—(If "YES," describe the circumstances.) m. Block 12. Have you had any aircraft accidents or incidents within the past 5 years?—(If "YES," describe the circumstances.) n. Block 13. Are you a U.S. citizen?—(You must enter "YES" or "NO.") NOTE: You are not required to be a U.S. citizen in order to be a designated examiner. o. Block 14. If you are NOT a U.S. citizen, enter the country in which you hold citizenship. If you hold dual citizenship, indicate the names of both countries.—Self-explanatory. p. Block 15. Do you read, write, speak, and understand English fluently?—Self-explanatory. q. Block 16. FAA certificates held—Enter all certificates held, their certificate numbers, and their ratings and limitations as shown on the certificate. NOTE: You must provide copies (front and back) of all certificates. r. Block 17. Enter all of your special training which is pertinent to the designation sought.—Self-explanatory. s. Block 18A. Have you ever served as a chief or assistant chief instructor in a school authorized under Title 14 of the Code of Federal Regulations (14 CFR) part 141?—(If "YES," enter the date(s).) t. Block 18B. Have you ever served as a check airman authorized under Title 14 of the Code of Federal Regulations (14 CFR) part 121 and/or part 135?—(If "YES," enter the date(s) and the FSDO.) FAA Form 8710-10 (1-00) ii NSN: 0052-00-918-0000 American LegalNet, Inc. www.FormsWorkFlow.com Form Approved OMB No. 2120-0033 04/30/2010 NATIONAL EXAMINER BOARD—DESIGNATED PILOT EXAMINER CANDIDATE APPLICATION Supplemental Information and Instructions (Continued) u. v. w. x. y. z. aa. bb. cc. dd. ee. ff. gg. hh. ii. jj. Block 18C. Have you ever been an FAA Aviation Safety Inspector?—(If "YES," enter the date(s) and the FSDO.) Block 19. Have you ever been a military pilot evaluator?—(If "YES," enter the date(s).) Block 20. Have you ever been an FAA Accident Prevention Counselor or FAA Aviation Safety Counselor?—(If "YES," enter the date(s) and the FSDO.) Block 21. Flight Experience—Enter all your actual flight time (in hours), as requested. Do not round off or approximate your hours (i.e., ±). Do not write in the shaded areas. Answer Blocks 21A through 21I, if applicable. NOTE: Total flight instruction given and/or instrument flight instruction given. (See the SPECIFIC ELIGIBILITY REQUIREMENTS criteria shown on pages iv and v.) Block 22. Work Experience—Describe your current or most recent work experience in Block 22A and work backwards. Use a separate block for each position described (e.g., Block 22A, Block 22B, etc.). Describe all of your work experience in specific detail that pertains to your qualifications for the designation(s) sought. Describe each applicable position you held during at least the past 5 years. You may describe work experience accrued more than 5 years ago. Include military service if your military experience is pertinent to your application for an examiner designation. (1) Complete the name, address, and telephone number of the employer/organization. (2) Job Title: Self-explanatory. (3) Dates Employed: Enter the dates of employment. (4) Supervisor's Name: Self-explanatory. (5) Reason for Leaving: Self-explanatory. (6) Description of Duties: Enter a complete description of the duties performed during this period of employment. Block 23. Briefly summarize your aviation activities and professional responsibilities that best qualify you to be a designated pilot examiner.—Self-explanatory. Block 24. During the past 5 years, were you fired from any job for any reason?—NOTE: If you answer "YES," you MUST enter the full details in Block 31. Block 25. Have you ever been convicted of any felony violation?—NOTE: If you answer "YES," you MUST enter the full details in Block 31. Block 26. Are you now under charges for any violation of law?—NOTE: If you answer "YES," you MUST enter the full details in Block 31. Block 27. Have you ever been imprisoned, been on probation, or been on parole?—NOTE: If you answer "YES," you MUST enter the full details in Block 31. Block 28. Have you ever been convicted by a military court-martial?—NOTE: If you answer "YES," you MUST enter the full details in Block 31. Block 29. Have you ever been discharged from a military service under a General discharge?—NOTE: If you answer "YES," you MUST enter the full details in Block 31. Block 30. Have you ever been discharged from a military service under other than honorable conditions?—NOTE: If you answer "YES," you MUST enter the full details in Block 31. Block 31. If you answered "YES" to any questions in Blocks 24 through 30, you MUST enter the full details. Block 32. Education and Training—Are you a high school graduate? (If "YES," enter the name of the high school and the date you graduated.) Are you a GED graduate? (If "YES," enter the date you received the GED.) (1) College and/or Technical Training Dates: Enter the beginning and ending dates of the training that you attended. (2) Name of School: Enter the name of the school(s) you attended. (3) Curriculum or Study Program: Enter the curriculum or study program for each school(s) listed. (4) Degree or Certificate Received: Enter degrees or certificates you received from each school(s) listed. Block 33. Applicant's Signature—After you read the "RELEASE OF INFORMATION AND CERTIFICATION STATEMENT" and the "NOTICE," sign the application, in black ink. After you sign your name, print or type your name under your signature. Enter the date you signed the application using eight-digit, numeric characters (e.g., 08/09/1999 not August 9, 1999). FAA Form 8710-10 (1-00) iii NSN: 0052-00-918-0000 American LegalNet, Inc. www.FormsWorkFlow.com Form Approved OMB No. 2120-0033 04/30/2010 NATIONAL EXAMINER BOARD—DESIGNATED PILOT EXAMINER CANDIDATE APPLICATION Supplemental Information and Instructions (Continued) LIST OF FLIGHT STANDARDS DISTRICT OFFICES ALASKAN REGION (AAL) ANC FSDO-03 ANCHORAGE, AK FAI FSDO-01 FAIRBANKS, AK JNU FSDO-05 JUNEAU, AK CENTRAL REGION (ACE) DSM FSDO-01 DES MOINES, IA ICT FSDO-07 WICHITA, KS LNK FSDO-09 LINCOLN, NE MCI FSDO-05 KANSAS CITY, MO STL FSDO-03 ST. ANN/ ST. LOUIS, MO EASTERN REGION (AEA) ABE FSDO-05 ALLENTOWN, PA FRG FSDO-11 FARMINGDALE, NY AGC FSDO-03 W. MIFFLIN/ PITTSBURGH, PA ALB FSDO-01 ALBANY, NY BAL FSDO-07 BALTIMORE, MD CRW FSDO-09 CHARLESTON, WV DCA FSDO-27 CHANTILLY, VA WASH, DC HAR FSDO-13 NEW CUMBERLAND/ HARRISBURG, PA PHL FSDO-17 PHILADELPHIA,PA NYC FSDO-15 GARDEN CITY, NY PIT FSDO-19 CORAOPOLIS/ PITTSBURGH, PA RIC FSDO-21 SANDSTON/ RICHMOND, VA ROC FSDO-23 ROCHESTER, NY TEB FSDO-25 TETERBORO, NJ NY IFO-29 JAMAICA, NY GREAT LAKES REGION (AGL) CLE FSDO-25 CLEVELAND, OH CMH FSDO-07 COLUMBUS, OH CVG FSDO-05 CINCINNATI, OH DPA FSDO-03 WEST CHICAGO, IL DTW FSDO-23 BELLEVILLE, MI FAR FSDO-21 FARGO, ND GRR FSDO-09 GRAND RAPIDS, MI IND FSDO-11 INDIANAPOLIS, IN MKE FSDO-13 MILWAUKEE, WI MSP FSDO-15 MINNEAPOLIS, MN ORD FSDO-31 SCHILLER PARK, IL RAP FSDO-27 RAPID CITY, SD SBN FSDO-17 SOUTH BEND, IN SPI FSDO-19 SPRINGFIELD, IL NEW ENGLAND REGION (ANE) BED FSDO-01 BEDFORD, MA BDL FSDO-03 WINDSOR LOCKS, CT BOS FSDO-02 BOSTON, MA PWM FSDO-05 PORTLAND, ME NORTHWEST MOUNTAIN REGION (ANM) BOI FSDO-11 BOISE, ID CPR FSDO-04 CASPER, WY DEN FSDO-03 DENVER, CO GEG FSDO-13 SPOKANE, WA HLN FSDO-05 HELENA, MT PDX FSDO-09 HILLSBORO/ PORTLAND, OR SEA FSDO-01 SEATTLE, WA SLC FSDO-07 SALT LAKE CITY, UT DEN FSDO-30 DENVER, CO SOUTHERN REGION (ASO) ATL FSDO-11 COLLEGE PARK/ ATLANTA, GA BHM FSDO-09 BIRMINGHAM, AL BNA FSDO-03 NASHVILLE, TN CAE FSDO-13 WEST COLUMBIA, SC FLL FSDO-17 FT. LAUDERDALE, FL TPA-FSDO-35 TAMPA, FL INT FSDO-05 WINSTON-SALEM, NC JAN FSDO-07 JACKSON, MS LOU FSDO-01 LOUISVILLE, KY MEM FSDO-25 MEMPHIS, TN MIA FSDO-19 MIAMI, FL ORL FSDO-15 ORLANDO, FL CLT FSDO-33 CHARLOTTE, NC SJU FSDO-21 SAN JUAN, PR TPA FSDO TAMPA, FL SOUTHWEST REGION (ASW) ABQ FSDO-01 ALBUQUERQUE, NM BTR FSDO-03 BATON ROUGE, LA DAL FSDO-05 DALLAS, TX DFW FSDO-07 DALLAS, TX FTW FSDO-19 FT. WORTH, TX HOU FSDO-09 HOUSTON, TX LBB FSDO-13 LUBBOCK, TX LIT FSDO-11 LITTLE ROCK, AR OKC FSDO-15 OKLA. CITY, OK SAT FSDO-17 SAN ANTONIO, TX WESTERN PACIFIC REGION (AWP) FAT FSDO-17 FRESNO, CA HNL FSDO-13 HONOLULU, HI LAS FSDO-19 LAS VEGAS, NV LAX FSDO-23 LOS ANGELES, CA LGB FSDO-05 LONG BEACH, CA OAK FSDO-27 OAKLAND, CA RAL FSDO-21 RIVERSIDE, CA RNO FSDO-11 RENO, NV SAC FSDO-25 SACRAMENTO, CA SAN FSDO-09 SAN DIEGO, CA SDL FSDO-07 SCOTTSDALE, AZ SJC FSDO-15 SAN JOSE, CA VNY FSDO-01 VAN NUYS, CA SFO FSDO-03 SAN FRANCISCO, CA INTERNATIONAL FIELD OFFICE LIST FRA IFO-EA33 FRANKFURT SIN IFO-WP33 SINGAPORE BRX IFO-EA31 BRUSSELS LGW IFO-EA35 LONDON MIA IFO-SO23 MIAMI SPNGS, FL DFW IFO-SW23 DALLAS, TX SPECIFIC ELIGIBILITY REQUIREMENTS FOR PRIVATE PILOT EXAMINER (PE) DESIGNEES ELIGIBILITY REQUIREMENTS CERTIFICATES REQUIRED CERTIFICATE CATEGORIES RATINGS HOURS AS PIC HOURS AS FLIGHT INSTRUCTOR (as a CFI or as a Military Flight Instructor) AIRPLANE Commercial Pilot Flight Instructor Both with Airplane category Both with appropriate airplane class rating(s) Instrument-Airplane on pilot certificate only 2,000 • 1,000 in airplanes that include 300 in past year • 300 in airplane class • 100 at night 500 in airplanes • 100 in class FAA Form 8710-10 (1-00) ROTORCRAFT Commercial Pilot Flight Instructor Both with Rotorcraft category GLIDERS Commercial Pilot Flight Instructor Both with Glider category 1,000 • 500 in rotorcraft that include at least 100 in past year • 250 in helicopters or 150 in gyroplanes, as appropriate 200 in helicopters or gyroplanes, as appropriate iv 500 • 200 in gliders that include 10 hours in past year of at least 10 flights 100 in gliders L-T-A BALLOON Commercial Pilot Lighter Than Air Lighter Than Air Airship class rating Helicopter or Gyroplane class rating(s), as appropriate L-T-A AIRSHIPS Commercial Pilot Balloon class rating 1,000 • 500 in airships that include at least 200 in past year • 50 at night 200 • 100 in balloons that include 20 hours in past year of at least 10 flights each of at least 30 minutes duration 50 in balloons • 10 in past year 100 in airships NSN: 0052-00-918-0000 American LegalNet, Inc. www.FormsWorkFlow.com Form Approved OMB No. 2120-0033 04/30/2010 NATIONAL EXAMINER BOARD—DESIGNATED PILOT EXAMINER CANDIDATE APPLICATION Supplemental Information and Instructions (Continued) SPECIFIC ELIGIBILITY REQUIREMENTS FOR COMMERCIAL PILOT EXAMINER (CE) DESIGNEES ELIGIBILITY REQUIREMENTS CERTIFICATES REQUIRED AIRPLANE CERTIFICATE CATEGORIES RATINGS ROTORCRAFT (VFR ONLY) Commercial Pilot Flight Instructor Both with Rotorcraft category Helicopter or Gyroplane class rating(s), as appropriate 2,000 • 500 in rotorcraft that include at least 100 in past year • 250 in helicopters or 150 in gyroplanes, as appropriate. • If applicable, 100 in large helicopters that include 50 in the type helicopter sought, and 25 in each additional type sought 200 in helicopters or gyroplanes, as appropriate. • 50 in helicopters or gyroplanes, as appropriate, preparing pilots for a Commercial Pilot Certificate HOURS AS PIC HOURS AS FLIGHT INSTRUCTOR (as a CFI or as a Military Flight Instructor) GLIDERS Commercial Pilot Flight Instructor Both with Glider category L-T-A AIRSHIPS Commercial Pilot L-T-A BALLOON Commercial Pilot Lighter-Than-Air Lighter-Than-Air Airship class rating Balloon class rating 500 • 250 in gliders that include at least 20 hours in the past year of at least 50 flights 2,000 • 500 in airships that include at least 200 in past year • 50 at night 200 • 100 in gliders 100 in airships 200 • 100 in balloons that include at least 20 hours in past year of at least 10 flights each of at least 30 minutes duration • Held a Commercial Pilot CertificateBalloon for at least 1 year 50 in balloons • 10 in the past year SPECIFIC ELIGIBILITY REQUIREMENTS FOR COMMERCIAL AND INSTRUMENT RATING EXAMINER (CIRE) AND AIRLINE TRANSPORT PILOT EXAMINER (ATPE) DESIGNEES ELIGIBILITY REQUIREMENTS TYPE OF CIRE DESIGNATION AIRPLANE & INSTRUMENT HELICOPTER & INSTRUMENT TYPE OF ATPE DESIGNATION AIRPLANE HELICOPTER CERTIFICATES REQUIRED CERTIFICATE CATEGORIES RATINGS Commercial Pilot Flight Instructor Both with Airplane category Both with appropriate airplane class ratings and Instrument-Airplane Commercial Pilot Flight Instructor Both with Rotorcraft category Airline Transport Pilot Flight Instructor Both with Airplane category Airline Transport Pilot Flight Instructor Both with Rotorcraft category Helicopter class rating; Instrument-Helicopter Both with Helicopter rating and instrument privileges on ATP and Instrument-Helicopter on CFI HOURS AS PIC 2,000 • 1,000 in airplanes that include 300 in airplanes in past year • 500 in class of airplane • 100 at night in airplanes • 200 in complex airplanes • 100 instrument flight (actual or simulated) • If applicable, 300 in large or turbine-power airplanes, that include 50 in type sought and 25 in each additional type sought 500 in airplanes • 100 in class of airplane • 250 instrument flight instructor time, that includes 200 in airplanes 2,000 • 500 in helicopters that include 100 in helicopters in past year • 100 instrument flight (actual or simulated) • If applicable, 100 in large helicopters, that include 50 in type sought and 25 in each additional type sought Both with appropriate airplane class rating(s) and instrument privileges on ATP and InstrumentAirplane on CFI 2,000 • 1,500 in airplanes, that include 300 in airplanes in past year • 500 in class airplane • 100 at night in airplanes • 200 complex airplanes • 100 instrument flight (actual or simulated) • If applicable, 300 in large or turbine-power airplanes, that include 50 in type sought and 25 in each additional type sought 500 in airplanes • 100 in class of airplane • 250 instrument flight instructor time, that include 200 in airplanes • 150 preparing pilots for Commercial Pilot or ATP with airplane category or type rating or InstrumentAirplane rating HOURS AS FLIGHT INSTRUCTOR (as a CFI or as a Military Flight Instructor) FAA Form 8710-10 (1-00) 250 in helicopters • 50 instrument flight instruction in helicopters • 100 preparing pilots for Commercial Pilot-Helicopter v 2,000 • 1200 in helicopters, that include 100 in helicopters in past year • 100 instrument flight (actual or simulated) • If applicable, 100 in large helicopters, that include 50 in type sought and 25 in each additional type sought 250 in helicopters • 50 of instrument flight instruction in helicopters • 100 in helicopters preparing pilots for Commercial Pilot Certificate or ATP Certificate with a Helicopter class or type rating or InstrumentHelicopter rating NSN: 0052-00-918-0000 American LegalNet, Inc. www.FormsWorkFlow.com Form Approved OMB No. 2120-0033 04/30/2010 NATIONAL EXAMINER BOARD—DESIGNATED PILOT EXAMINER CANDIDATE APPLICATION U.S. Department of Transportation Federal Aviation Administration 2. Social Security Number— - 1. Name (Last, First, Middle)— 3. Permanent Mailing Address— City: State: 5. This application is for:— Initial Application for NEB Renewal Application for NEB Reinstatement (other than initial designating FSDO) for NEB 2A. Date of Birth— 4. Telephone Numbers— Home Phone: ( ) Zip Code: Business Phone: ( ) Fax Number: ( ) 7. Type of designation(s) sought:— 6. Have you ever held an FAA pilot examiner designation in any region?— (If "Yes," enter the date(s) and the supervising PE FSDO.) CE YES NO ATPE From (mo/yr):____________ CIRE To (mo/yr):______________ FSDO:__________________ 8. Enter the categories, classes, and types of aircraft for which authorization is sought.— _____________________________________ 9. Enter the FSDO that has jurisdiction in the area where you desire to serve.— ____________________________________ 10. Enter the names of other FSDO's in whose areas you can provide examiner service on a regular basis, if any.— ______________________________________________ _____________________________________ ____________________________________ ______________________________________________ _____________________________________ ____________________________________ ______________________________________________ _____________________________________ ____________________________________ ______________________________________________ 11. Has any certificate or rating issued to you ever been revoked?— (If "YES," describe the circumstances.) 12. Have you had any aircraft accidents or incidents within the past 5 years?— (If "YES," describe the circumstances.) YES NO __________________________________________________________ YES NO _______________________________________________________________ __________________________________________________________ _______________________________________________________________ __________________________________________________________ _______________________________________________________________ __________________________________________________________ _______________________________________________________________ __________________________________________________________ _______________________________________________________________ 13. Are you a U.S. citizen?— YES NO 14. If you are NOT a U.S. citizen, enter the country in which you hold citizenship. If you hold dual citizenship, indicate the names of both countries.— ____________________________________ 15. Do you read, write, speak, and understand English fluently?— YES NO 16. FAA certificates held—You MUST provide copies (front and back) of all certificates. Certificate Number Type of Certificate _______________________________________ ______________________________________ Ratings and Limitations (as shown on the certificate) _________________________________________________ _______________________________________ ______________________________________ _________________________________________________ _______________________________________ ______________________________________ _________________________________________________ 17. Enter all of your special training which is pertinent to the designation sought.— __________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________ FAA Form 8710-10 (1-00) 1 NSN: 0052-00-918-0000 American LegalNet, Inc. www.FormsWorkFlow.com Form Approved OMB No. 2120-0033 18A. Have you ever served as a chief or assistant chief instructor in a school authorized under Title 14 of the Code of Federal Regulations (14 CFR) part 141?— (If "YES," enter the date(s).) YES NO From (mo/yr):_____________ To (mo/yr):_____________ 18B. Have you ever served as a check airman authorized under Title 14 of the Code of Federal Regulations (14 CFR) part 121 and/or part 135?— (If "YES," enter the date(s) and the FSDO.) YES NO From (mo/yr):_____________ To (mo/yr):_____________ FSDO:____________________________________ 18C. Have you ever been an FAA Aviation Safety Inspector?—(If "YES," enter the date(s) and the FSDO.) YES NO From (mo/yr):_____________ To (mo/yr):_____________FSDO:_________________________________________ 19. Have you ever been a military pilot evaluator?—(If "YES," enter the date(s).) YES NO From (mo/yr):_____________ To (mo/yr):_____________ 20. Have you been an FAA Accident Prevention Counselor or FAA Aviation Safety Counselor?—(If "YES," enter the date(s) and the FSDO.) YES NO From (mo/yr):_____________To (mo/yr):_______________FSDO:___________________________________________ 21. Flight Experience—Enter all your actual flight time (in hours), as requested. Do not round off or approximate your hours (i.e., ±). Do not write in the shaded areas. Answer Blocks 21A through 21I, if applicable. NOTE: Total flight instruction given and/or instrument flight instruction given. (See the SPECIFIC ELIGIBILITY REQUIREMENTS 21A. Enter turbine-powered large airplanes and or large helicopters.— criteria shown on pages iv and v.) Aircraft Class/ Experience PIC Total PIC Last 12 Mos. Total (NonInstrument) Flight Instruction Given (Civilian/ Military) Instrument Flight Instruction Given PIC Night Instrument Flight (Actual/ Simulated) ASEL / / / / AMES / / Helicopter / PIC Total / ASES Aircraft Make and Model / AMEL Flight Instruction Given (Balloons Last 12 Mos.) / Gyroplane Glider Airship Balloon 21B. Enter number of glider flights as PIC within the past year.—______________________________________________________________________________ 21C. Enter number of balloon flights as PIC that were at least 30 minutes duration within the past year.—______________________________________________ FAA Form 8710-10 (1-00) 2 NSN: 0052-00-918-0000 American LegalNet, Inc. www.FormsWorkFlow.com Form Approved OMB No. 2120-0033 21D. Enter number of hours as PIC in complex airplanes.—___________________________________________________________________________________ 21E. Enter number of hours flight instruction given in rotorcraft preparing pilots for commercial pilot certificate.—__________________ 21F. Enter date your commercial balloon certificate was acquired.—____________________________________________________________________________ 21G. Enter number of hours flight instruction given in airplanes preparing pilots for an ATP certificate, an instrument rating, or a type rating.—________________ 21H. Enter number of hours flight instruction given in helicopters preparing pilots for an ATP certificate, an instrument rating, or a type rating.—_______________ 21I. Enter number of pilot and/or flight instructor certification practical tests completed within the past year (as FAA Aviation Safety Inspector).—_____________ 22. Work Experience—Describe your current or most recent work experience in Block 22A and work backwards. Use a separate block for each position described (e.g., Block 22A, Block 22B, etc.). Describe all of your work experience in specific detail that pertains to your qualifications for the designation(s) sought. Describe each applicable position you held during at least the past 5 years. You may describe work experience accrued more than 5 years ago. Include military service if your military experience is pertinent to your application for an examiner designation. 22A. Name of Employer/Organization: Telephone Number ( ) Address: City: Job Title: State: Dates Employed (mo/yr): From: Zip Code: Supervisor's Name: To: Reason for Leaving: Description of Duties: 22B. Name of Employer/Organization: Telephone Number ( ) Address: City: Job Title: State: Dates Employed (mo/yr): From: Zip Code: Supervisor's Name: To: Reason for Leaving: Description of Duties: 22C. Name of Employer/Organization: Telephone Number ( ) Address: City: FAA Form 8710-10 (1-00) State: 3 Zip Code: NSN: 0052-00-918-0000 American LegalNet, Inc. www.FormsWorkFlow.com Form Approved OMB No. 2120-0033 Job Title: Dates Employed (mo/yr): From: To: Supervisor's Name: Reason for Leaving: Description of Duties: 22D. Name of Employer/Organization: Telephone Number ( ) Address: City: Job Title: State: Dates Employed (mo/yr): From: To: Zip Code: Supervisor's Name: Reason for Leaving: Description of Duties: 22E. Name of Employer/Organization: Telephone Number ( ) Address: City: Job Title: State: Dates Employed (mo/yr): From: To: Zip Code: Supervisor's Name: Reason for Leaving: Description of Duties: 22F. Name of Employer/Organization: Telephone Number ( ) Address: City: Job Title: State: Dates Employed (mo/yr): From: To: Zip Code: Supervisor's Name: Reason for Leaving: Description of Duties: FAA Form 8710-10 (1-00) 4 NSN: 0052-00-918-0000 American LegalNet, Inc. www.FormsWorkFlow.com Form Approved OMB No. 2120-0033 23. Briefly summarize your aviation activities and professional responsibilities that best qualify you to be a designated pilot examiner.— ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ 24. During the past 5 years, were you fired from any job for any reason?— 25. Have you ever been convicted of any felony violation?— 26. Are you now under charges for any violation of law?— 27. Have you ever been imprisoned, been on probation, or been on parole?— YES NO 30. Have you ever been discharged from a military service under other than honorable conditions?— YES NO YES NO YES NO YES NO 28. Have you ever been convicted by a military 29. Have you ever been discharged from a military court-martial?— service under a General discharge?— YES NO YES NO 31. If you answered "YES" to any questions in Blocks 24 through 30, you MUST enter the full details. _________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ 32. Education and Training— Are you a high school graduate? Are you a GED graduate? YES YES NO NO Name of High School:_______________________________Date Graduated (mo/yr):______________ Date received GED (mo/yr):__________________________ College and/or Technical Training Dates: Name of School: From (mo/yr): Curriculum or Study Program: Degree or Certificate Received: To (mo/yr): RELEASE OF INFORMATION AND CERTIFICATION STATEMENT— — Read this statement CAREFULLY. After you read this statement, you MUST sign and date this application in black ink. Under your signature, you MUST print or type your name. I understand that a false statement on any part of this application will be grounds for not approving this application, for rescinding my eligibility as an examiner Þ candidate, for not designating me, or terminating any designation I may receive. I understand that any information given may be investigated. Þ I consent to the release of information regarding my personal and technical qualifications for designation as a pilot examiner by employers, schools, law Þ enforcement agencies, and other individuals and organizations, to investigators, employees of the Federal government, and persons not employed by the Federal government to whom the FAA has delegated the authority to screen and approve or disapprove pilot examiner applicants. I understand that, if my application is accepted, approval for assignment to the national examiner candidate pool is dependent on my passing the examiner Þ predesignation knowledge test with a score of 80 percent or higher. I understand that assignment to the national examiner candidate pool does not guarantee selection or designation as a pilot examiner and that, if selected, Þ designation is dependent on satisfactory completion of a practical test (demonstration of competency) and satisfactory completion of the Initial Pilot Examiner Standardization Seminar. I understand that my FAA accident/incident/violation history will be verified at each stage of the application process. Þ I understand that designation as a pilot examiner is a privilege, not a right, and that any designation received may be terminated, revoked, or not renewed at any Þ time for any reason the FAA Administrator deems appropriate. I certify that, to the best of my knowledge and belief, all of my statements on this application are true, correct, complete, and made in good faith. Þ FAA Form 8710-10 (1-00) 5 NSN: 0052-00-918-0000 American LegalNet, Inc. www.FormsWorkFlow.com Form Approved OMB No. 2120-0033 33. Applicant's Signature —(Sign application in black ink.) —NOTICE—Whoever in any matter within the jurisdiction of any department or agency of the — United States knowingly and willfully falsifies, conceals or covers up by any trick, scheme, or device a material fact, or who makes any false, fictitious or fraudulent statements or representations, or entry, may be fined up to $250,000 or imprisoned not more than 5 years, or both. (18 U.S. Code Secs. 1001; 3571). Date signed—(Month, Day, Year) — (Print or type your name under your signature.) FAA Form 8710-10 (1/00) 6 NSN: 0052-00-918-0000 American LegalNet, Inc. www.FormsWorkFlow.com Form Approved OMB No. 2120-0033 FOR NATIONAL EXAMINER BOARD USE ONLY (For Original Issuance Only) Accepted for Predesignation Testing Not Qualified Date:_________________________ Predesignation Test Score:____________________ Date of Test:___________________ Approved for Pool Date:___________________ Disapproved for Pool Signature of NEB Official:___________________________________________ Title:______________________________________ Referred to:_____________________FSDO Selected Date:___________________ Declined Date:___________________ FOR FSDO USE ONLY: FAA Form 8710-6 may be used for renewals, additional authorizations, and/or reinstatements. Approve Inspector's Recommendation: Reason for Disapproval (Attach additional sheets, if required.): Disapprove The individual submitting this application has satisfactorily demonstrated competency to perform the duties of the following designation(s): PE Aircraft Categories: CE CIRE Airplane Rotorcraft Additional Qualifications/Limitations (if any): ATPE Glider FIE (Must have 1 year as CE/CIRE.) Lighter-Than-Air Inspector's Signature:_________________________________________________ Date: ________________________ FSDO:_____________________ Regional Office: Approve Disapprove Date: _____________________ Signature: ____________________________________________________________________ Routing Symbol: _____________________ FSDO: Certificate of Authority Issued: Date: ___________________________ Examiner Number: _______________________________________________ FSDO: ______________________ Expiration Date: ______________________ LOA(s) Issued: _______________ _______________ ________________ _________________ _________________ _________________ Additional FSDO's to be served by the examiner (if any): FAA Form 8710-10 (1/00) 7 NSN: 0052-00-918-0000 American LegalNet, Inc. www.FormsWorkFlow.com