TEAR OFF BEFORE USE U.S. Department of Transportation Federal Aviation Administration SUPPLEMENTAL INFORMATION This supplements the form appearing below, Airman Certificate and/or Rating Application. AIRMAN CERTIFICATE AND/OR RATING APPLICATION - PRIVACY ACT 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 TYPE OR PRINT ALL ENTRIES IN INK U.S. Department of Transportation Federal Aviation Administration Form Approved OMB. No. 2120-0022 11/30/2007 AIRMAN CERTIFICATE AND/OR RATING APPLICATION MECHANIC AIRFRAME POWERPLANT APPLICATION FOR: ORIGINAL ISSUANCE A. NAME (First, Middle, Last) (Specify Rating) ADDED RATING REPAIRMAN PARACHUTE RIGGER SENIOR SEAT MASTER CHEST LAP ' BACK K. PERMANENT MAILING ADDRESS I. APPLICANT INFORMATION B. SOCIAL SECURITY NO. C. DOB (Mo., Day., Yr.) D. HEIGHT IN. E. WEIGHT NUMBER AND STREET, P.O. BOX, ETC. 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 SPECIFY TYPE: DATE OF FINAL CONVICTION NO YES C. LETTER OF RECOMMENDATION FOR REPAIRMAN (Attach copy) L. HAVE YOU EVER HAD AN AIRMAN CERTIFICATE SUSPENDED OR REVOKED? NO 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? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A. CIVIL EXPERIENCE B. MILITARY EXPERIENCE (1) NAME AND LOCATION OF SCHOOL D. GRADUATE OF APPROVED COURSE (2) SCHOOL NO. (3) CURRICULUM FROM WHICH GRADUATED II. CERTIFICATE OR RATING APPLIED FOR ON BASIS OF - (4) DATE E. STUDENT HAS MADE SATISFACTORY PROGRESS AND IS RECOMMENDED TO TAKE THE ORAL/ PRACTICAL TEST (FAR 65.80) F. SPECIAL AUTHORIZATION TO TAKE MECHANIC'S ORAL/PRACTICAL TEST (FAR 65.80) A. MILITARY COMPETANCE OBTAINED IN (1) SERVICE (1) SCHOOL NAME NO. (2) SCHOOL OFFICIAL'S SIGNATURE (1) DATE AUTH. (2) DATE AUTH. EXPIRES (3) FAA INSPECTOR SIGNATURE (4) FAA DIST OFC. (2) RANK OR PAY LEVEL (3) MILITARY SPECIALITY CODE 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). III. RECORD OF EXPERIENCE DATES-MONTH AND YEAR FROM TO EMPLOYER AND LOCATION TYPE WORK PERFORMED SEAT C. PARACHUTE RIGGER APPLICANTS: INDICATE BY TYPE HOW MANY PARACHUTES PACKED CHEST BACK 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 B. DATE V.IENCE REQUIREMENTS OF FAR 65 AND IS Emp. .reg. D.O. .seal .con iss. Act I FIND THIS APPLICANT MEETS THE EXPER- DATE INSPECTOR'S SIGNATURE FAA DISTRICT OFFICE ELIGIBLE TO TAKE THE REQUIRED TESTS. .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 I. GENERAL - Airframe and powerplant ORAL TEST QUES. NO. PRACTICAL TEST PROJ. NO. II. AIRFRAME STRUCTURES ORAL TEST QUES. NO. PRACTICAL TEST PROJ. NO. III. AIRFRAME SYSTEMS AND COMPONENTS ORAL TEST QUES. NO. PRACTICAL TEST PROJ. NO. IV. POWERPLANT THEORY AND MAINTENANCE ORAL TEST QUES. NO. PRACTICAL TEST PROJ. NO. V. POWERPLANT SYSTEMS AND COMPONENTS ORAL TEST QUES. NO. PRACTICAL TEST PROJ. NO. PASS EXPIRATION DATE: FAIL PASS EXPIRATION DATE: FAIL PASS EXPIRATION DATE: FAIL PASS EXPIRATION DATE: FAIL PASS EXPIRATION DATE: FAIL PASS EXPIRATION DATE: FAIL PASS EXPIRATION DATE: FAIL PASS EXPIRATION DATE: FAIL PASS EXPIRATION DATE: FAIL PASS EXPIRATION DATE: FAIL SEAT BACK PARACHUTE RIGGER PASS PASS PASS PASS PASS REMARKS FAIL FAIL FAIL FAIL FAIL TYPE SUPERSEDED CERTIFICATE TEMPORARY CERTIFICATE CHEST LAP DESIGNATED EXAMINER'S REPORT I have personally tested this applicant in accordance with pertinent procedures and standards, and I HAVE INDICATED THE RESULT AS: ATTACHMENTS: DATE TEST COMPLETED APPROVED (Temporary Certificate Issued) DISAPPROVED REPORT OF WRITTEN TEST FAA FORM 8610-2 APPROVED (Temporary Certificate NOT Issued) FAR 65.80 - ORAL/PRACTICAL PASSED LETTER SEAL SYMBOL CARD DESIGNATION NO. EXAMINER'S SIGNATURE APPLICANT'S CERTIFICATION THIS BLOCK MUST BE COMPLETED BY THE APPLICANT AT THE TIME OF ISSUANCE OF TEMPORARY CERTIFICATE (FAA FORM 8060-4) NO Yes If "Yes," explain on an attached sheet. DATE OF FINAL CONVICTION NO YES