U.S. Department of Transportation Federal Aviation Administration FAA Form 8710-11, 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, 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 2120-0021. 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, Aviation Records on Individuals. The information collected on this form would be subject to the published routine uses of DOT.FAA 847. Those routine users are: (a) To provide basic airman 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 airman apprehension of drug-law 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 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 references 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. 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 FAA Form 8710-11 (02-04) American LegalNet, Inc. www.FormsWorkflow.com Form Approved OMB No: 2120-0690 07/31/2007 U.S. Department of Transportation Federal Aviation Administration Airman Certificate and/or Rating Application – Sport Pilot Student I. Application Information Airplane Sport Private Gyroplane Balloon Flight Instructor Proficiency Check Airship Additional Rating Powered Parachute Renewal Initial Reexamination Glider Weight Shift Control Reinstatement Reissuance of Other certificate A. Name (Last, First, Middle) B. SSN (US only) C. Date of Birth E. Address F. Citizenship Specify City, State, Zip Code USA H. Height M. Do you now hold, or have you ever held an FAA Pilot Certificate? N. Grade Pilot Certificate O. Certificate Number S. Date Issued T. Name of Examiner (Citizenship) Yes Q. Do you hold a Yes No Medical Certificate? G. Do you read, speak, write & understand the English language? J. Hair K. Eyes L. Sex Other I. Weight In. D. Place of Birth lbs. Yes No Male Female P. Date Issued No R. Class of Certificate U. Do you hold a US V. License Number W. State of Issuance X. Date Issued Yes No Za. Have you ever been convicted for violation of any Federal or State statutes relating to narcotic drugs, marijuana, or depressant Yes No or stimulant drugs or substances. Y. Expiration Date Driver’s License? Zb. Date of Final Conviction If Certificate, Privilege or Rating Applied For on Basis of: 1. Aircraft to be used (if flight test required) 2a. Total Time in this aircraft SIM/FTD 1) A. Completion of Required Test 1) 2) 2b. Pilot in Command 2) 1. Name and Location of Training Agency or Training Center 1) 2) hours 1a. Certification Number 2. Curriculum From Which Graduated 3. Date SIM) B. Graduate of Approved/Accepted Course 1. Country C. Holder of Foreign License Issued By FTD) hours 2. Grade of License 3. Number 4. Ratings 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 Takeoff Landings Night PIC Night Takeoff Landing PIC PIC PIC PIC SIC SIC PIC PIC SIC SIC Number of Powered Launches PIC SIC Number of Ground Launches SIC PIC Number of AeroTows PIC SIC Number of Flights SIC Airplanes Rotorcraft (Gyroplane Only) Gliders Lighter Than Air Weightshift Control Powered Parachute IV. Have you failed a test for this certificate, privilege or rating? Yes No V. Applicant’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 Date FAA Form 8710-11 (02-04) American LegalNet, Inc. www.FormsWorkflow.com Instructor’s Recommendation I have personally instructed the applicant and consider this person ready to take the test. Date Instructor’s Signature (Print name & Sign) Certificate No. Certificate Expires Air Agency’s Recommendation This applicant has successfully completed our Course, and is recommended for certification, privilege or rating without further Date test. Agency Name and Number Official’s 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 pilot certificate, privilege 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) Duration of Test Ground Simulator/FTD Type(s) of Aircraft Used 1) Certificate or Rating for which tested Date SIM) FTD) Registration No(s) 1) 2) Examiner’s Signature (Print Name & Sign) Certificate No. Flight 1) 2) 2) Designation No. Designation Expires Proficiency Check – Instructor’s Record I have successfully reviewed this applicants pilot logbook and/or training record and certify the individual meets the pertinent requirements of 14 CFR part 61 (Subparts K {61.419} or J{61.321} for the proficiency check sought. I have personally tested this applicant in accordance with the pertinent procedures and standards of 14 CFR pert 61 (Subparts K or J), and find the applicant proficient in and light-sport aircraft. Proficiency Check: Instructor’s Signature (Print Name & Sign) Date Satisfactory Unsatisfactory Certificate No. Expiration Date: 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) Satisfactory Unsatisfactory Proficiency Check: Location of Test (Facility, City, State) Duration of Test Ground Simulator/FTD Type(s) of Aircraft Used 1) Certificate or Rating for which tested Student Pilot Certificate Issued Examiner’s Recommendation ACCEPTED REJECTED SIM) FTD) Registration No(s) 1) 2) Certificate or Rating Based on Foreign License Approved Course Graduate Other Approved FAA Qualification Criteria Reissue or Exchange of Pilot Certificate Training Course (FIRC) Name Date Student Pilot Certificate (Copy) FAA District Office ID: Name: Form of ID Knowledge Test Report Temporary Airman Certificate Certificate No. Airman’s Identification (ID) 2) Flight Instructor Renewal Reinstatement Instructor Renewal Based on Activity Training Course Test Duties and Responsibilities Graduation Certificate No. Date Inspector’s Signature (Print Name & Sign) Attachments: Flight 1) 2) Date of Birth: Number Certificate Number: Notice of Disapproval Expiration Date Superseded Airman Certificate Telephone Number Email Address: FAA Form 8710-11 (02-04) American LegalNet, Inc. www.FormsWorkflow.com U.S. Department of Transportation Federal Aviation Administration Airman Certificate and/or Rating Application – Sport Pilot ADDITIONAL ADDRESS INFORMATION Name (Last, First, Middle) Social Security Number Certificate Number Date Issued Permanent Mailing Address: Address the applicant requests the certificate to be sent: Street Street P.O. Box P.O. Box City, State, Zip Code City, State, Zip Code Physical Description as entered: Comments: FAA Form 8710-11 (02-04) American LegalNet, Inc. www.FormsWorkflow.com This Page intentionally left blank American LegalNet, Inc. www.FormsWorkflow.com