Form Approved OMB NO. 2120-0033 04/30/2010 TYPE OF DESIGNATION PRIVATE PILOT EXAMINER DESIGNATION U.S. Department of Transportation AND QUALIFICATION RECORD Federal Aviation Administration Attach supplemental sheets if more space is required for any item Telephone No. 1. NAME (Last, first, middle) 2. ADDRESS (Number, street, city, state, and ZIP code) COMMERCIAL PILOT EXAMINER AIRLINE TRANSPORT PILOT EXAMINER PROFICIENCY PILOT EXAMINER FLIGHT ENGINEER EXAMINER FLIGHT INSTRUCTOR EXAMINER OTHER 3. DATE OF BIRTH (Month, day, and year) 4. U.S. CITIZEN YES NO 5. DO YOU NOW HOLD, OR HAVE YOU EVER HELD, AN EXAMINER DESIGNATION TYPE AND NUMBER YES NO 6. HAS ANY CERTIFICATE OR RATING ISSUED YOU EVER BEEN SUSPENDED OR REVOKED OR HAVE YOU PAID A CIVIL PENALTY AS A RESULT OF A VIOLATION OF THE FEDERAL AVIATION REGULATIONS. (Complete for original designations only) YES NO 7. CERTIFICATES HELD TYPE CERTIFICATE NO. RATINGS DATE ISSUED 8. FLIGHT EXPERIENCE (in hours) AIRPLANE TOTAL ROTORTYPE LAST 12 MO TOTAL LAST 12 MO GLIDERS TOTAL LAST 12 MO AIRSHIPS TOTAL LAST 12 MO INSTRUMENT FLIGHT (Actual or sim) NIGHT FLIGHT PILOT-IN-COMMAND FLIGHT INSTRUCTION GIVEN COPILOT FLIGHT NAVIGATOR FLIGHT ENGINEER 9. EMPLOYMENT (Indicate professional experience pertinent to this designation) EMPLOYER'S NAME NATURE OF WORK DATES TITLE OF POSITION 10. SPECIAL TRAINING PERTINENT TO THE DESIGNATION CERTIFICATION: I certify that I am familiar with the requirements for this designation, its privileges and limitations, and that the information stated herein is true. It is understood that this designation may be terminated upon notice by the FAA for the reasons specified in section 183.15(c) of the Federal Aviation Regulations. PAPERWORK REDUCTION ACT STATEMENT: The information collected on this form is necessary to determine applicant eligibility for Designated Pilot Examiner, Proficiency Pilot Examiner and Airman Certification Representative. The information is used to determine certification eligibility. We estimate that it will take 30 minutes to complete the form. The information collection is required to obtain a benefit. The information collected becomes part of the Privacy Act system of records DOT/FAA 830, Representatives of the Administrator. Please 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 OMB control number associated with this collection 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. DATE FAA Form 8710-6 (10-95) Supersedes Previous Edition SIGNATURE Electronic Forms (PDF) NSN: 0052-00-036-7003 American LegalNet, Inc. www.FormsWorkflow.com FOR FAA USE DATE LAST REPORT SUBMITTED FLIGHT TEST ACTIVITIES-GENERAL AVIATION TYPE OF ACTION (Complete for renewals and additional designations) ORIGINAL ISSUANCE TOTAL SUBMITTED CERTIFICATES/RATINGS RENEWAL DISAPPROVED BY EXAMINER ACCEPTED BY INSPECTOR RECHECKED BY INSPECTOR NO. RETURNED FOR CORRECTION PRIVATE PILOT COMMERCIAL PILOT ADDITIONAL AUTHORITY AIRLINE TRANSPORT PILOT INSTRUMENT RATING SPOT CHECK ONLYNO RENEWAL EFFECTED PRIVATE ADDITIONAL RATINGS REINSTATEMENT COMMERCIAL ATR Complete for original issuance and reinstatements only CHARACTER AND REPUTATION (Include industry and community reputation as well as personal knowledge possessed by FAA personnel) PROFESSIONAL ABILITY (Brief narrative description of examiner indoctrination and training given and results expressed as "'good," " excellent," or "unsatisfactory.") APPROVE INSPECTOR'S RECOMMENDATION/ACTION DISAPPROVE JUSTIFICATION FOR APPROVAL/REASONS FOR DISAPPROVAL The individual named has been flight tested/examined and deemed competent to perform the duties of the designation indicated below. DESIGNATION CATEGORY PRIVATE PILOT ADDITIONAL QUALIFICATIONS LIMITATIONS (For pilot flight engineer examiner give aircraft category) AIRPLANE COMMERCIAL PILOT EXAMINER AIRLINE ROTORCRAFT PROFICIENCY PILOT EXAMINER GLIDER FLIGHT ENGINEER EXAMINER FLIGHT INSTRUCTOR EXAMINER AIRSHIP OFFICE NO. DATE INSPECTOR'S SIGNATURE PRIVACY ACT STATEMENT. The information on this form is solicited under authority of the Federal Aviation Regulations Pan 183. The purpose of this information is to establish your qualifications as an examiner. Submission of the data is mandatory. Incomplete submission may result in delay or denial of your request. The data will be used to determine your eligibility as an examiner, and for statistical purposes. In addition, the data also becomes part of the Privacy Act system of records DOT/FAA 830, Representatives of the Administrator, and is subject to the additional conditions of that published system. CONCUR DATE REGIONAL OFFICE ACTION SIGNATURE DISAPPROVE TYPE OF DESIGNATION NO. FAA Form 8710-6 (10-95) Supersedes Previous Edition Electronic Forms (PDF) CERTIFICATE OF AUTHORITY ISSUED DO TO SERVE UNDER EXPIRATION DATE NSN: 0052-00-036-7003 American LegalNet, Inc. www.FormsWorkflow.com