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 I. Application Information Airman Certificate and/or Rating Application � Sport Pilot Sport Gyroplane Private Balloon Initial Reissuance of B. SSN (US only) F. Citizenship USA H. Height In. (Citizenship) Other I. Weight lbs. O. Certificate Number T. Name of Examiner Y. Expiration Date Zb. Date of Final Conviction Airship Renewal Proficiency Check Glider Additional Rating Powered Parachute Reinstatement certificate C. Date of Birth Specify Other D. Place of Birth Weight Shift Control Student Airplane Flight Instructor Reexamination A. Name (Last, First, Middle) E. Address City, State, Zip Code M. Do you now hold, or have you ever held an FAA Pilot Certificate? Yes Q. Do you hold a Medical Certificate? U. Do you hold a US Driver's License? Yes No R. Class of Certificate No G. Do you read, speak, write & understand the English language? J. Hair K. Eyes L. Sex Yes No N. Grade Pilot Certificate S. Date Issued Male Female P. Date Issued 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. If Certificate, Privilege or Rating Applied For on Basis of: 1. Aircraft to be used (if flight test required) A. Completion of Required Test B. Graduate of Approved/Accepted Course 1) 2) 2a. Total Time in this aircraft SIM/FTD 1) SIM) 1. Name and Location of Training Agency or Training Center 2. Curriculum From Which Graduated 1. Country C. Holder of Foreign License Issued By 4. Ratings 2. Grade of License 2) FTD) hours 2b. Pilot in Command 1) 2) hours 1a. Certification Number 3. Date 3. Number 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 Number of Flights Number of AeroTows Number of Ground Launches Number of Powered Launches PIC Airplanes SIC Rotorcraft (Gyroplane Only) PIC SIC PIC SIC PIC SIC PIC SIC PIC SIC PIC SIC PIC SIC 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 FAA Form 8710-11 (02-04) Date 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 recommended for certification, privilege or rating without further Date Agency Name and Number Course, and is tes