TEAR OFF BEFORE USE U.S. Department of Transportation Federal Aviation Administration SUPPLEMENTAL INFORMATION AIRMAN CERTIFICATE AND/OR RATING APPLICATION - PRIVACY ACT This supplements the form appearing below, Airman Certificate and/or Rating Application. The information on the form is solicited under authority of Federal Aviation Regulations, Part 65. Submission of all the data is mandatory except for Social Security Account Number which Is voluntary. The purpose of this information is to establish eligibility for certification and/or airman rating. The data will be used to identify and evaluate your qualifications and eligibility for the issuance of an airman certificate and/or rating. Certification cannot be completed unless the data is complete. Disclosure of your Social Security Account Number is optional: Disclosure will facilitate maintenance of your records which are maintained in alphabetical order and cross referenced with your SSAN and airman number to provide prompt access. In the event of nondisclosure a unique number will be assigned to your file. Paperwork Reduction Act Statement: The information collected on this form is necessary to ensure applicant eligibility. The information is used to determine that the applicant meets the necessary qualifications as a Mechanic, Repairman, or Parachute Rigger. We estimate that it will take approximately 20 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 847, Aviation Records on Individuals. 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 displays a currently valid OMB control number. The OMB control number associated with this collection is 2120-0022. 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. FAA Form 8610-2 (2-85) Electronic Version (Adobe) American LegalNet, Inc. www.FormsWorkflow.com Form Approved OMB. No. 2120-0022 11/30/2007 TYPE OR PRINT ALL ENTRIES IN INK U.S. Department of Transportation Federal Aviation Administration AIRMAN CERTIFICATE AND/OR RATING APPLICATION MECHANIC REPAIRMAN PARACHUTE RIGGER AIRFRAME SENIOR POWERPLANT APPLICATION FOR: (Specify Rating) ORIGINAL ISSUANCE ADDED RATING CHEST BACK ' LAP K. PERMANENT MAILING ADDRESS A. NAME (First, Middle, Last) I. APPLICANT INFORMATION MASTER SEAT B. SOCIAL SECURITY NO. C. DOB (Mo., Day., Yr.) D. HEIGHT E. WEIGHT NUMBER AND STREET, P.O. BOX, ETC. IN. F. HAIR G. EYES H. SEX I. NATIONALITY (Citizenship) CITY J. PLACE OF BIRTH STATE ZIP CODE M. DO YOU NOW OR HAVE YOU EVER HELD AN FAA AIRMAN CERTIFICATE? NO YES L. HAVE YOU EVER HAD AN AIRMAN CERTIFICATE SUSPENDED OR REVOKED? NO SPECIFY TYPE: YES (If "Yes," explain on an attached sheet keying to appropriate item number). N. HAVE YOU EVER BEEN CONVICTED FOR VIOLATION OF ANY FEDERAL OR STATE STATUTES PERTAINING TO NARCOTIC DRUGS, MARIJUANA, AND DEPRESSANT OR STIMULANT DRUGS OR SUBSTANCES? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B. MILITARY EXPERIENCE A. CIVIL EXPERIENCE II. CERTIFICATE OR RATING APPLIED FOR ON BASIS OF - DATE OF FINAL CONVICTION NO YES C. LETTER OF RECOMMENDATION FOR REPAIRMAN (Attach copy) (1) NAME AND LOCATION OF SCHOOL D. GRADUATE OF APPROVED COURSE (2) SCHOOL NO. (3) CURRICULUM FROM WHICH GRADUATED E. STUDENT HAS MADE SATISFACTORY PROGRESS AND IS RECOMMENDED TO TAKE THE ORAL/ PRACTICAL TEST (FAR 65.80) (1) SCHOOL NAME (1) SERVICE A. MILITARY COMPETANCE OBTAINED IN NO. (2) SCHOOL OFFICIAL'S SIGNATURE (2) DATE AUTH. EXPIRES (3) FAA INSPECTOR SIGNATURE (1) DATE AUTH. F. SPECIAL AUTHORIZATION TO TAKE MECHANIC'S ORAL/PRACTICAL TEST (FAR 65.80) (4) DATE (2) RANK OR PAY LEVEL (4) FAA DIST OFC. (3) MILITARY SPECIALITY CODE III. RECORD OF EXPERIENCE B. APPLICANT'S OTHER THAN FAA CERTIFICATED SCHOOL GRADUATES. LIST EXPERIENCE RELATING TO CERTIFICATE AND RATING APPLIED FOR. (Continue on separate sheet, if more space is needed). DATES-MONTH AND YEAR FROM EMPLOYER AND LOCATION TO SEAT CHEST BACK C. PARACHUTE RIGGER APPLICANTS: INDICATE BY TYPE HOW MANY PARACHUTES PACKED TYPE WORK PERFORMED LAP FOR MASTER RATING ONLY PACKED AS A SENIOR RIGGER MILITARY RIGGER I CERTIFY THAT THE STATEMENTS BY ME ON THIS APPLICATION ARE TRUE IV. APPLICANT'S CERTIFICATION A. SIGNATURE I FIND THIS APPLICANT MEETS THE EXPER- V.IENCE REQUIREMENTS OF FAR 65 AND IS B. DATE DATE INSPECTOR'S SIGNATURE FAA DISTRICT OFFICE ELIGIBLE TO TAKE THE REQUIRED TESTS. Emp. .reg. D.O. .seal .con iss. Act .lev .TR .s.h. .Src #rte FOR FAA USE ONLY Rating (1) Rating (2) Rating (3) Rating (4) LIMITATIONS FAA Form 8610-2 (2-85) SUPERSEDES PREVIOUS EDITION Electronic Version (Adobe) American LegalNet, Inc. www.FormsWorkflow.com Results of Oral and Practical Tests MECHANIC PARACHUTE RIGGER I. GENERAL - Airframe and powerplant PASS EXPIRATION DATE: PRACTICAL TEST PASS FAIL CHEST PASS FAIL LAP FAIL FAIL BACK FAIL TYPE PASS QUES. NO. PASS PASS FAIL PASS ORAL TEST SEAT EXPIRATION DATE: FAIL PROJ. NO. REMARKS II. AIRFRAME STRUCTURES ORAL TEST PASS EXPIRATION DATE: FAIL PASS EXPIRATION DATE: FAIL QUES. NO. PRACTICAL TEST PROJ. NO. III. AIRFRAME SYSTEMS AND COMPONENTS ORAL TEST PASS EXPIRATION DATE: FAIL PASS EXPIRATION DATE: FAIL QUES. NO. PRACTICAL TEST PROJ. NO. IV. POWERPLANT THEORY AND MAINTENANCE ORAL TEST PASS EXPIRATION DATE: FAIL PASS EXPIRATION DATE: FAIL QUES. NO. PRACTICAL TEST PROJ. NO. V. POWERPLANT SYSTEMS AND COMPONENTS ORAL TEST PASS EXPIRATION DATE: FAIL PASS EXPIRATION DATE: FAIL QUES. NO. PRACTICAL TEST PROJ. NO. DESIGNATED EXAMINER'S REPORT I have personally tested this applicant in accordance with pertinent procedures and standards, and I HAVE INDICATED APPROVED (Temporary Certificate Issued) APPROVED (Temporary Certificate NOT Issued) THE RESULT AS: DISAPPROVED FAR 65.80 - ORAL/PRACTICAL PASSED REPORT OF WRITTEN TEST DATE TEST COMPLETED SUPERSEDED CERTIFICATE LETTER FAA FORM 8610-2 ATTACHMENTS: TEMPORARY CERTIFICATE SEAL SYMBOL CARD EXAMINER'S SIGNATURE DESIGNATION NO. APPLICANT'S CERTIFICATION THIS BLOCK MUST BE COMPLETED BY THE APPLICANT AT THE TIME OF ISSUANCE OF TEMPORARY CERTIFICATE (FAA FORM 8060-4) A. HAVE YOU EVER HAD AN AIRMAN CERTIFICATE SUSPENDED OR REVOKED? . . . . . . . . . . . . . . . B. HAVE YOU EVER BEEN CONVICTED FOR VIOLATION OF ANY FEDERAL OR STATES STATUTES PERTAINING TO NARCOTIC DRUGS, MARIJUANA, DEPRESSANT OR STIMULANT DRUGS OR SUBSTANCES? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I CERTIFY THAT THE STATEMENTS BY ME ARE TRUE. NO Yes If "Yes," explain on an attached sheet. DATE OF FINAL CONVICTION NO YES B. DATE A. SIGNATURE FAA INSPECTOR'S REPORT I HAVE WITH THE INDICATED RESULT EXAMINED THIS APPLICANT'S PAPERS. APPROVED PERSONALLY TESTED THIS APPLICANT IN ACCORDANCE WITH PERTINENT PROCEDURES AND STANDARDS. DISAPPROVED DATE INSPECTOR'S SIGNATURE Electronic Version (Adobe) PARACHUTE SEAL SYMBOL ASSIGNED ANSWER SHEET GRADED (Military Competency) FAA DISTRICT OFFICE American LegalNet, Inc. www.FormsWorkflow.com