U.S. Department of Transportation Federal Aviation Administration FAA Form 8710-1, Airman Certificate and/or Rating Application Supplemental Information and Instructions Paperwork Reduction Act Statement: The information collected on this form is necessary to determine applicant eligibility for airman ratings. We estimate it will take 15 minutes to complete this form. The information collected is required to obtain a benefit and becomes part of the Privacy Act system of records DOT/FAA 847, General Air Transportation Records on Individuals. 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 2120-0021. 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. Privacy Act The information on the accompanying form is solicited under authority of Title 14 of the Code of Federal Regulations (14 CFR), Part 61. The purpose of this data is to be used to identify and evaluate your qualifications and eligibility for the issuance of an airman certificate and/or rating. Submission of all requested data is mandatory, except for the Social Security Number (SSN) which is voluntary. Failure to provide all the required information would result in you not being issued a certificate and/or rating. The information would become part of the Privacy Act system of records DOT/FAA 847, General Air Transportation Records on Individuals. The information collected on this form would be subject to the published routine uses of DOT/FAA 847. Those routine uses are: (a) To provide basic airmen certification and qualification information to the public upon request. (b) To disclose information to the national Transportation Safety Board (NTSB) in connection with its investigation responsibilities. (c) To provide information about airmen to Federal, state, and local law enforcement agencies when engaged in the investigation and apprehension of drug violators. (d) To provide information about enforcement actions arising out of violations of the Federal Aviation regulations to government agencies, the aviation industry, and the public upon request. (e) To disclose information to another Federal agency, or to a court or an administrative tribunal, when the Government or one of its agencies is a party to a judicial proceeding before the court or involved in administrative proceedings before the tribunal. Submission of your Social Security Number is voluntary. Disclosure of your SSN will facilitate maintenance of your records which are maintained in alphabetical order and cross-referenced with your SSN and airman certificate number to provide prompt access. In the event of nondisclosure, a unique number will be assigned to your file. See Privacy Act Information above. Detach this part before submitting form. Instructions for completing this form (FAA 8710-1) are on the reverse. If an electronic form is not printed on a duplex printer, the applicant's name, date of birth, and certificate number (if applicable) must be furnished on the reverse side of the application. This information is required for identification purposes. The telephone number and E-mail address are optional. Tear off this cover sheet before submitting this form. FAA Form 8710-1 (4-00) Supersedes Previous Edition NSN: 0052-00-682-5007 American LegalNet, Inc. www.FormsWorkflow.com AIRMAN CERTIFICATE AND/OR RATING APPLICATION INSTRUCTIONS FOR COMPLETING FAA FORM 8710-1 I. APPLICATION INFORMATION. Check appropriate blocks(s). Block A. Name. Enter legal name. Use no more than one middle name for Block S. Date Issued. Enter the date your medical certificate was issued. record purposes. Do not change the name on subsequent applications unless it is done in accordance with 14 CFR Section 61.25. If you do not have a middle name, enter “NMN”. If you have a middle initial only, indicate “Initial only.” If you are a Jr., or a II, or III, so indicate. If you have an FAA certificate, the name on the application should be the same as the name on the certificate unless you have had it changed in accordance with 14 CFR Section 61.25. Block T. Name of Examiner. Enter the name as shown on medical Block B. Social Security Number. Optional: See supplemental give the date of final conviction. Information Privacy Act. Do not leave blank: Use only US Social Security Number. Enter either “SSN” or the words “Do not Use” or “None.” SSN’s are not shown on certificates. Block C. Date of Birth. Check for accuracy. Enter eight digits; Use numeric characters, i.e., 07-09-1925 instead of July 9, 1925. Check to see that DOB is the same as it is on the medical certificate. Block D. Place of Birth. If you were born in the USA, enter the city and state where you were born. If the city is unknown, enter the county and state. If you were born outside the USA, enter the name of the city and country where you were born. Block E. Permanent Mailing Address. Enter residence number and street, P.O. Box or rural route number in the top part of the block above the line. The City, State, and ZIP code go in the bottom part of the block below the line. Check for accuracy. Make sure the numbers are not transposed. FAA policy requires that you use your permanent mailing address. Justification must be provided on a separate sheet of paper signed and submitted with the application when a PO Box or rural route number is used in place of your permanent physical address. A map or directions must be provided if a physical address is unavailable. Block F. Citizenship. Check USA if applicable. If not, enter the country where you are a citizen. Block G. Do you read, speak, write and understand the English language? Check yes or no. Block H. Height. Enter your height in inches. Example: 5’8” would be entered as 68 in. No fractions, use whole inches only. Block I. Weight. Enter your weight in pounds. No fractions, use whole certificate. Block U. Narcotics, Drugs. Check appropriate block. Only check “Yes” if you have actually been convicted. If you have been charged with a violation which has not been adjudicated, check .“No”. Block V. Date of Final Conviction. If block “U” was checked “Yes” II. CERTIFICATE OR RATING APPLIED FOR ON BASIS OF: Block A. Completion of Required Test. 1. AIRCRAFT TO BE USED. (If flight test required) – Enter the make and model of each aircraft used. If simulator or FTD, indicate. 2. TOTAL TIME IN THIS AIRCRAFT (Hrs.) – (a) Enter the total Flight Time in each make and model. (b) Pilot-In-Command Flight Time - In each make and model. Block B. Military Competence Obtained In. Enter your branch of service, date rated as a military pilot, your rank, or grade and service number. In block 4a or 4b, enter the make and model of each military aircraft used to qualify (as appropriate). Block C. Graduate of Approved Course. 1. NAME AND LOCATION OF TRAINING AGENCY/CENTER. As shown on the graduation certificate. Be sure the location is entered. 2. AGENCY SCHOOL/CENTER CERTIFICATION NUMBER. As shown on the graduation certificate. Indicate if 142 training center. 3. CURRICULUM FROM WHICH GRADUATED. As shown on the graduation certificate. 4. DATE. Date of graduation from indicated course. Approved course graduate must also complete Block “A” COMPLETION OF REQUIRED TEST. Block D. Holder of Foreign License Issued By. 1. COUNTRY. Country which issued the license. 2. GRADE OF LICENSE. Grade of license issued, i.e., private, commercial, etc. 3. NUMBER. Number which appears on the license. 4. RATINGS. All ratings that appear on the license. pounds only. Block E. Completion of Air Carrier’s Approved Training Program. Block J. Hair. Spell out the color of your hair. If bald, enter “Bald.” 1. Name of Air Carrier. 2. Date program was completed. 3. Identify the Training Curriculum. Color should be listed as black, red, brown, blond, or gray. If you wear a wig or toupee, enter the color of your hair under the wig or toupee. Block K. Eyes. Spell out the color of your eyes. The color should be listed as blue, brown, black, hazel, green, or gray. Block L. Sex. Check male or female. Block M. Do You Now Hold or Have You Ever Held An FAA Pilot Certificate? Check yes or no. (NOTE: A student pilot certificate is a “Pilot Certificate.”) III. RECORD OF PILOT TIME. The minimum pilot experience required by the appropriate regulation must be entered. It is recommended, however, that ALL pilot time be entered. If decimal points are used, be sure they are legible. Night flying must be entered when required. You should fill in the blocks that apply and ignore the blocks that do not. Second In Command “SIC” time used may be entered in the appropriate blocks. Flight Simulator, Flight Training Device and PCATD time may be entered in the boxes provided. Total, Instruction received, and Instrument Time should be entered in the top, middle, or bottom of the boxes provided as appropriate. Block N. Grade of Pilot Certificate. Enter the grade of pilot certificate (i.e., Student, Recreational, Private, Commercial, or ATP). Do NOT enter flight instructor certificate information. IV. HAVE YOU FAILED A TEST FOR THIS CERTIFICATE OR RATING? Check appropriate block. Block O. Certificate Number. Enter the number as it appears on your V. APPLICANT’S CERTIFICATION. pilot certificate. Block P. Date Issued. Enter the date your pilot certificate was issued. A. SIGNATURE. The way you normally sign your name. B. DATE. The date you sign the application. Block Q. Do You Now Hold A Medical Certificate? Check yes or no. If yes, complete Blocks R, S, and T. Block R. Class of Certificate. Enter the class as shown on the medical certificate, i.e., 1st, 2nd, or 3rd class. FAA Form 8710-1 (4-00) Supersedes Previous Edition American LegalNet, Inc. NSN: 0052-00-682-5007 www.FormsWorkflow.com Form Approved OMB No: 2120-0021 07/31/2007 TYPE OR PRINT ALL ENTRIES IN INK DEPARTMENT OF TRANSPORTATION FEDERAL AVIATION ADMINISTRATION Airman Certificate and/or Rating Application l Application Information Student Recreational Private Commercial Additional Rating Airplane Single-Engine Airplane Multiengine Rotorcraft Flight Instructor ____ Initial ____ Renewal ____ Reinstatement Additional Instructor Rating Medical Flight Test Reexamination Reissuance of ____________________________ certificate Airline Transport Balloon Ground Instructor B. SSN (US Only) C. Date of Birth Month E. Address F. Citizenship Specify City, State, Zip Code H. Height M. Do you now hold, or have you ever held an FAA Pilot Certificate? N. Grade Pilot Certificate Day D. Place of Birth Year G. Do you read, speak, write, & understand the English language? Yes Other ________________ I. Weight Instrument Glider Powered-Lift Other ______________________ A. Name (Last, First, Middle) USA Airship J. Hair K. Eyes L. Sex No Male Female Yes Q. Do you hold a Medical Certificate? Yes O. Certificate Number P. Date Issued No R. Class of Certificate S. Date Issued T. Name of Examiner No U. Have you ever been convicted for violation of any Federal or State statutes relating to narcotic drugs, marijuana, or depressant or stimulant drugs or substances? Yes V. Date of Final Conviction No II. Certificate or Rating Applied For on Basis of: A. B. Completion of Required Test Military Competence Obtained In C. 1. Aircraft to be used (if flight test required) 2a. Total time in this aircraft / SIM / FTD 1. Service 2b. Pilot in command 2. Date Rated hours 4a. Flown 10 hours PIC in last 12 months in the following Military Aircraft. hours 3. Rank or Grade and Service Number 4b. US Military PIC & Instrument check in last 12 months (List Aircraft) Course D. 1. Name and Location of Training Agency or Training Center 1a. Certification Number 2. Curriculum From Which Graduated Graduate of Approved 3. Date 1. Country 2. Grade of License 3. Number Holder of Foreign License Issued By E. Completion of Air Carrier's Approved 4. Ratings 1. Name of Air Carrier 2. Date 3. Which Curriculum Training Program Initial Upgrade Transition III RECORD OF PILOT TIME (Do not write in the shaded areas.) Total Instruction Received Solo Pilot in Command (PIC) Cross Country Instruction Received Cross Country Solo Cross Country PIC Instrument Night Instruction Received Night Take-off/ Landings Night PIC Night Take-Off/ Landing PIC PIC Powered Lift PIC SIC SIC PIC SIC SIC PIC PIC PIC SIC SIC Number of Powered Launches SIC SIC Number of Ground Launches PIC SIC Number of Aero-Tows SIC PIC PIC Rotor­ craft PIC SIC PIC Airplanes Number of Flights PIC SIC Gliders Lighter Than Air Simulator Training Device PCATD IV. Have you failed a test for this certificate or rating? Yes No V. Applicants's Certification -- I certify that all statements and answers provided by me on this application form are complete and true to the best of my knowledge and I agree that they are to be considered as part of the basis for issuance of any FAA certificate to me. I have also read and understand the Privacy Act statement that accompanies this form. Signature of Applicant FAA Form 8710-1 (4-00) Supersedes Previous Edition Date NSN: 0052-00-682-5007 American LegalNet, Inc. www.FormsWorkflow.com Instructor's Recommendation I have personally instructed the applicant and consider this person ready to take the test. Instructor's Signature (Print Name & Sign) Certificate No: Date Certificate Expires Air Agency's Recommendation The applicant has successfully completed our _________________________________________________________course, and is recommended for certification or rating without further _____________________________________________test. Date Agency Name and Number Officials Signature Title Designated Examiner or Airman Certification Representative Report Student Pilot Certificate Issued (Copy attached) I have personally reviewed this applicant's pilot logbook and/or training record, and certify that the individual meets the pertinent requirements of 14 CFR Part 61 for the certificate or rating sought. I have personally reviewed this applicant's graduation certificate, and found it to be appropriate and in order, and have returned the certificate. I have personally tested and/or verified this applicant in accordance with pertinent procedures and standards with the result indicated below. Approved -- Temporary Certificate Issued (Original Attached) Disapproved -- Disapproval Notice Issued (Original Attached) Location of Test (Facility, City, State) Ground Certificate or Rating for Which Tested Date Type(s) of Aircraft Used Examiner's Signature (Print Name & Sign) Duration of Test Simulator/FTD Flight Registration No.(s) Certificate No. Designation No. Designation Expires Evaluator's Record (Use For ATP Certificate and/or Type Ratings) Inspector Examiner Oral Signature and Certificate Number Date _______________________________________________________________ __________________________ Approved Simulator/Training Device Check _______________________________________________________________ __________________________ Aircraft Flight Check _______________________________________________________________ __________________________ Advanced Qualification Program _______________________________________________________________ __________________________ Aviation Safety Inspector or Technician Report I have personally tested this applicant in accordance with or have otherwise verified that this applicant complies with pertinent procedures, standards, policies, and or necessary requirements with the result indicated below. Approved -- Temporary Certificate Issued (Original Attached) Disapproved -- Disapproval Notice Issued (Original Attached) Location of Test (Facility, City, State) Duration of Test Simulator/FTD Ground Certificate or Rating for Which Tested Student Pilot Certificate Issued Examiner's Recommendation Accepted Rejected Type(s) of Aircraft Used Certificate or Rating Based on Registration No.(s) Flight Instructor Military Competence Approved Course Graduate Special Medical test conducted -- report forwarded Reinstatement Instructor Renewal Based on Other Approved FAA Qualification Criteria Activity Test to Aeromedical Certification Branch, AAM-330 Training Course (FIRC) Name Date Inspector's Signature Attachments: Graduation Certificate No. (Print Name & Sign) __________________________________________________ Form of ID Knowledge Test Report __________________________________________________ Number __________________________________________________ Expiration Date __________________________________________________ Telephone Number Notice of Disapproval Certificate No. Training Course Duties and Responsibilities Date FAA District Office Airman's Identification (ID) Student Pilot Certificate (Copy) Temporary Airman Certificate Ground Instructor Renewal Foreign License Reissue or Exchange of Pilot Certificate Flight ID: Name: _____________________________________________ Date of Birth: _______________________________________ Certificate Number: __________________________________ E-Mail Address ______________________________________ Superseded Airman Certificate FAA Form 8710-1 (4-00) Supersedes Previous Edition NSN: 0052-00-682-5007 American LegalNet, Inc. www.FormsWorkflow.com