Form Approved OMB No. 2120-0033 04/30/2010 APPLICATION AND STATEMENT OF QUALIFICATION (DME/DPRE/DAR-T/ODAR-T) U.S. Department of Transportation Federal Aviation Administration Supplemental Application and Instructions Paperwork Reduction Act Statement The information collected on this form is necessary to determine applicant eligibility for DME, DPRE, DAR-T, or ODAR-T. The information is used to determine certification eligibility. We estimate that it will take 55 minutes to complete the form. Completion of this form is required to obtain a benefit. The inf ormation c ollected be comes pa rt of the P rivacy A ct s ystem of re cords; D OT/FAA 830, R epresentatives of the Administrator; and confidentiality pursuant to the provisions of the P rivacy A ct is g ranted. Please note tha t a n a gency m ay no t c onduct or sponsor, and a person is not r equired to r espond to, a collection of information unless it dis plays a c urrently valid OMB control number. The OMB control number associated with this collection is 2120-0033. 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. Detach all supplemental information and instruction sheets before submitting application. DESIGNEE/EXAMINER CANDIDATE APPLICATION PROCEDURES HOW TO APPLY For Initial Designations: 1. Complete, sign, and date this application. Complete all applicable blocks fully. Use additional sheets of blank paper if you need more space to complete the answers to a block. Be sure to indicate the number of the block you are answering at the top of the blank sheet. 2. Use a separate sheet for each block requiring additional space. Attach all additional blank sheets to this application. 3. Block 7. See definitions and qualification criteria on page ii of these instructions. 4. Applicants for DAR-T designations must attach a letter of recommendation in accordance with FAA Order 8100.8 latest revision, Designee Management Handbook. WHERE TO SEND APPLICATION FOR INITIAL DESIGNATION (DME, DPRE, and DAR-T applicants ONLY.) ODAR-T applicants will submit this form to the local FSDO or IFO. 1. Your completed application with all attached sheets should be sent to: Federal Aviation Administration Designee Standardization Branch, AFS-640 ATTN: National Examiner Board P.O. Box 25082 Oklahoma City, OK 73125-0082 2. Keep a copy of this application for your personal records. WHAT HAPPENS TO YOUR APPLICATION Your a pplication w ill be e valuated by the Na tional Ex aminer Boa rd (NEB) to e nsure tha t y ou m eet the se lection criteria for the designation sought. The NEB will advise you by letter whether or not you meet the applicable criteria. If you meet this criteria, the letter from the NEB will state that your application has been accepted and instruct you to complete the examiner predesignation knowledge test. If you do not m eet the selection criteria, the NEB will advise you how the deficiency may be corrected. Do not take the predesignation knowledge test until receiving a letter of acceptance from the NEB. Applicants for designation as DAR-T’s are not required to take a Predesignation Test. Upon receiving notification that your application has been accepted, take the appropriate predesignation knowledge test at any FAA computerized testing center. Request the Aviation Mechanic Examiner Test or the Parachute Rigger Examiner Test. You must forward test results to the NEB within 10 days of the date you complete the test. Keep a copy of the test report for your personal records. Upon r eceiving th e ap plicant’s test rep ort with a sco re o f 8 0 p ercent o r h igher, th e NEB w ill n otify th e ap plicant o f ap proval/nonapproval f or assignment to the national examiner candidate pool. In accordance with candidates’ indicated geographic availability, qualifications, and ranking within the pool, the NEB forwards candidate applications to each FSDO requesting a new designee. Your application will be kept on file in the NEB candidate pool for a period of 2 years or until you are selected for designation, whichever comes first. After 2 y ears, a pplications of a ll c andidates not s elected f or de signation w ill be de leted from the NEB pool. An applicant must re peat the application process in order to apply for reassignment to the candidate pool. FAA Form 8110-28 (1-01) Supersedes Previous Edition i NSN: 0052-00-917-0001 American LegalNet, Inc. www.FormsWorkFlow.com PRIVACY ACT STATEMENT: This statement is provided pursuant to the Privacy Act of 1974, 5 USC § 552a: The authority for collecting this information is contained in 49 U.S.C. §§ 40113, 44702, 44703, 44709 and 14 C.F.R. Part 6 1. The principal purpose for which the information is intended to be used is to identify and evaluate your qualifications and eligibility for the issuance of an airman certificate and/or rating. Submission of the data is mandatory, except for the Social Security Number, which is voluntary. Failure to provide all required information will result in our being unable to issue you a certificate and/or rating. The information collected on this form will be included in a Privacy Act System of Records known as DOT/FAA 847, titled “Aviation Records on Individuals” and will be subject to the routine uses published in the System of Records Notice (SORN) for DOT/FAA 847 (see www.dot.gov/privacy/privacyactnotices), including: (a) Providing basic airmen certification and qualification information to the public upon request; examples of basic information include: • The type of certificates and ratings held, limitations, date of issuance and certificate number; • The status of the airman’s certificate (i.e., whether it is current or has been amended, modified, suspended or revoked for any reason); • The airman’s home address, unless requested by the airman to be withheld from public disclosure per 49 U.S.C. 44703(c); • Information relating to an airman’s physical status or condition used to determine statistically the validity of FAA medical standards; and the date, class, and restrictions of the latest physical • Information relating to an individual’s eligibility for medical certification, requests for exemption from medical requirements, and requests for review of certificate denials. (b) Using contact information to inform airmen of meetings and seminars conducted by the FAA regarding aviation safety. (c) Disclosing information to the National Transportation Safety Board (NTSB) in connection with its investigation responsibilities. (d) Providing information about airmen to Federal, State, local and tribal law enforcement agencies when engaged in an official investigation in which an airman is involved. (e) Providing information about enforcement actions, or orders issued thereunder, to Federal agencies, the aviation industry, and the public upon request. (f) Making records of delinquent civil penalties owed to the FAA available to the U.S. Department of the Treasury and the U.S. Department of Justice (DOJ) for collection pursuant to 31 U.S.C. 3711(g). (g) Making records of effective orders against the certificates of airmen available to their employers if the airmen use the affected certificates to perform job responsibilities for those employers. (h) Making airmen records available to users of FAA’s Safety Performance Analysis System (SPAS), including the Department of Defense Commercial Airlift Division’s Air Carrier Analysis Support System (ACAS) for its use in identifying safety hazards and risk areas, targeting inspection efforts for certificate holders of greatest risk, and monitoring the effectiveness of targeted oversight actions. (i) Making records of an individual’s positive drug test result, alcohol test result of 0.04 or greater breath alcohol concentration, or refusal to submit to testing required under a DOT-required testing program, available to third parties, including current and prospective employers of such individuals. Such records also contain the names and titles of individuals who, in their commercial capacity, administer the drug and alcohol testing programs of aviation entities. (j) Providing information about airmen through the Civil Aviation Registry’s Comprehensive Airmen Information System to the Department of Health and Human Services, Office of Child Support Enforcement, and the Federal Parent Locator Service that locates noncustodial parents who owe child support. Records in this system are used to identify airmen to the child support agencies nationwide in enforcing child support obligations, establishing paternity, establishing and modifying support orders and location of obligors. Records listed within the section on Categories of Records are retrieved using Connect: Direct through the Social Security Administration’s secure environment. (k) Making personally identifiable information about airmen available to other Federal agencies for the purpose of verifying the accuracy and completeness of medical information provided to FAA in connection with applications for airmen medical certification. (l) Making records of past airman medical certification history data available to Aviation Medical Examiners (AMEs) on a routine basis so that AMEs may render the best medical certification decision. (m) Making airman, aircraft and operator record elements available to users of FAA’s Skywatch system, including the Department of Defense (DoD), the Department of Homeland Security (DHS), DOJ and other authorized Federal agencies, for their use in managing, tracking and reporting aviation-related security events. (n) Other possible routine uses published in the Federal Register (see Prefatory Statement of General Routine Uses for additional uses (65 F.R. 19477-78) For example, a record from this system of records may be disclosed to the United States Coast Guard (Coast Guard) and to the Transportation Security Administration (TSA) if information from this system was shared with either agency when that agency was a component of the Department of Transportation (DOT) before its transfer to DHS and such disclosure is necessary to accomplish a DOT, TSA or Coast Guard function related to this system of records. American LegalNet, Inc. www.FormsWorkFlow.com Form Approved OMB No. 2120-0033 04/30/2010 DESIGNEES/EXAMINERS APPLYING FOR RENEWAL, ADDITIONAL AUTHORIZATIONS, AND/OR REINSTATEMENTS. Designees/Examiners applying for renewal, additional authorizations, or reinstatement should complete blocks 1, 2, 4, 5, 6, 7, 7b (if applicable), 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, and 23a, and return it directly to the designating FSDO. Renewal applications shall be submitted to the designating FSDO 45 days before the designee’s/examiner’s current designation expires. TYPES OF DESIGNATIONS AND QUALIFICATION CRITERIA Definition DME - Designated Mechanic Examiner General Qualifications The applicant must: 1. Have held a valid aviation mechanic certificate for 5 years with the rating(s) for which designation is to be issued. 2. Have been actively exercising the privileges of a valid aviation mechanic certificate for 3 years immediately prior to designation. 3. Be at least 23 years of age. 4. Show evidence of a high level of aeronautical knowledge in the subject areas required for aviation mechanic certification in both reciprocating and turbine-engine aircraft. 5. Have a good record as a mechanic, as a person engaged in the industry and community with a reputation for honesty and dependability. 6. Have a fixed base of operation adequately equipped to exercise the authority of designation. Definition DPRE - Designated Parachute Rigger Examiner General Qualifications The applicant must: 1. Have held a valid master parachute rigger certificate for 2 years. 2. Have been actively exercising the privileges of a valid master parachute rigger certificate for 2 years immediately prior to designation. 3. Be at least 23 years of age. 4. Show evidence of a high level of knowledge in the subject areas required for the parachute rigger certification. 5. Have a good record as a parachute rigger, as a person engaged in the industry and community with a reputation for honesty and dependability. 6. Have a fixed base of operation adequately equipped to exercise the authority of the designation. Definition DAR-T - Designated Airworthiness Representative-Maintenance/ODAR-T Organizational Designated Airworthiness RepresentativeMaintenance General Qualifications.— To qualify for an appointment as a DAR-T, all applicants (including those persons in an ODAR-T who will perform the authorized function(s)) must meet the general qualifications listed below, in addition to having the experience specified in FAA Order 8100.8 latest revision, as appropriate for the particular function for which authorization is being sought: The applicant must: 1. Be current and possess a thorough working knowledge of pertinent CFR’s, directives, and related guidance material. 2. Possess current technical knowledge and experience commensurate with that required for the particular function (e.g., Boeing Airplane: Models 707-100, 747SP, etc; Bell Helicopter Models: 47B, 47H, etc.; and/or related parts/components and/or appliances, etc.). 3. Have unquestionable integrity, a cooperative attitude, and the ability to exercise sound judgment. 4. Have the ability to maintain the highest degree of objectivity while performing authorized functions on behalf of the FAA, consistent with FAA regulations, statutes, and safety goals, notwithstanding any influence to the contrary. 5. Have at least 2 years satisfactory experience working directly in connection with the type work to be covered in the authorized function(s). 6. Have a good command of the English language, both oral and written. 7. Hold a valid aviation mechanic certificate with Airframe and Powerplant (A&P) ratings. Instructions for Completing FAA Form 8110-28 Designated Mechanic Examiner (DME), Designated Parachute Rigger Examiner (DPRE), Designated Airworthiness Representative-Maintenance (DAR-T) and Organizational Designated Airworthiness Representative-Maintenance (ODAR-T) Application and Statement of Qualifications 1. All entries on FAA Form 8110-28 must be made in permanent ink or typewritten. 2. Read the “PRIVACY ACT” statement attached to FAA Form 8110-28. Remove the “PRIVACY ACT” statement portion before submitting FAA Form 8110-28. 3. Complete blocks 1 through 23a as follows: Block 1. NAME (Last, First, Middle). (1) Enter your legal name. For record purposes, no more than one middle name may be entered. (2) If you have no middle name, enter “NMN” (no middle name) or “NMI” (no middle initial). (3) If you have initial(s) only, enter the initials and then enter “INITIALS ONLY.” (4) If you are a junior, III, IV, etc., so indicate. Block 2. PERMANENT MAILING ADDRESS — Enter all required information, to include Number and Street, P.O. Box, City, State, and Zip Code. FAA Form 8110-28 (1-01) Supersedes Previous Edition ii NSN: 0052-00-917-0001 American LegalNet, Inc. www.FormsWorkFlow.com Form Approved OMB No. 2120-0033 04/30/2010 Note: If a P.O. Box or Rural Route is used, you must furnish (on a separate sheet of paper) the directions required to find your residence. This becomes par t of th e appl ication and m ust be s igned by y ou, th e appl icant. T he fo llowing s hows an e xample of one appl icant’s additional statement. Example: “I live 2 miles north of state h ighway 37 on Peachtree Lane in a tw o-story house with large barn in the back.” (You must sign this statement.) Block 3. U.S. CITIZEN — You must check Yes or No. Block 3A. COUNTRY IN WHICH YOU HOLD CITIZENSHIP — Enter name of country. If dual citizenship is held, indicate the names of both countries. Block 3B. DAR–T Repairmen must enter the certificate number(s) of the repair station where they perform work. Block 4. SOCIAL SECURITY NUMBER. (1) Completing Block 4 is optional. (See “PRIVACY ACT” STATEMENT.) (2) Enter your SSN or either “DO NOT USE” or “NONE.” Block 5. DATE OF BIRTH — Use six–digit, numeric characters, i.e., 08–09–60; not August 9, 1960. Block 6. TELEPHONE NUMBER — Provide a home telephone number and a business telephone number including area code and extension, if applicable. Block 7. DESIGNATION SOUGHT (1) DME applicants will check the “Designated Mechanic Examiner” box and will check the “Airframe” rating box for the Airframe rating, the “P owerplant” rat ing b ox f or t he P owerplant rat ing, o r b oth t he “Airframe” an d “Powerplant” rating boxes for the Airframe and Powerplant (A&P) rating. (2) DPRE applicants will check the “Designated Parachute Rigger Examiner” box and will check the “Seat” rating box for the Seat type rating, the “Back” rating box for the Back type rating, the “Chest” rating box for the Chest type rating and the “LAP” rating box for the Lap type rating. DPRE’s are required to hold at least two parachute rigger type ratings, i.e.; Seat and Back, Seat and Chest, Back and Chest, etc., and hold a Master Parachute Rigger Rating. (3) DAR-T/ODAR–T applicants will check the De signated A irworthiness Re presentative (Ma intenance only ) box a nd ide ntify spe cific function(s) cu rrently au thorized t o p erform i n acco rdance w ith p rocedures set forth in AC 183-35 la test re vision, A irworthiness Designee Function Codes and Consolidated Directory for DMIR/DAR/DAS/DOA and SFAR No. 36, and/or FAA Order 8100.8 latest revision, Designee Management Handbook, for which an appointment is sought in block 7b. Block 7a. FSDO OR IFO OF JURISDICTION — From the list on page iv of this application, enter the FSDO or IFO that has jurisdiction in the area or location where you are presently located. Block 7b. DAR-T/ODAR-T APPLICANT’S FUNCTION(S) — DAR–T/ODAR–T applicants will identify specific functions which they are currently authorized to perform in accordance with AC 183-35 latest revision and /or FAA Order 8100.8 latest revision for which designation is sought. (Maintenance Functions only) Block 8. EDUCATION AND TRAINING — Enter all formal education. (1) Dates: Enter the beginning and ending dates of the training [including general education (i.e. high school, GED, etc.)] that you attended. Use six-digit, numeric characters (i.e., 08-09-60). Do not use August 9, 1960. (2) Name of School: Enter the name of the school where training was received. (3) Curriculum: Enter the school’s curriculum: i.e.; Airframe, Powerplant, or Airframe and Powerplant (A&P). (4) Degree or Certificate: Enter the degree or type of certificate received (i.e., AA/BS/BA/MA/MB). Block 9. FAA CERTIFICATES NOW HELD PERTINENT TO DESIGNATION SOUGHT (1) Enter type certificate(s) held-Mechanic, Master Parachute Rigger, or Repairmen’s Certificate. (2) Enter the certificate number for each type certificate. (3) Enter the rating(s) you hold: i.e., Airframe, Powerplant, Airframe and Powerplant; or Parachute Rigger with Seat, Back, Chest, or Lap ratings. (4) Enter the original date the certificate(s) and rating(s) were issued. (If the certificate was lost and a new one was issued, or you have added a rating your present certificate will not have the original date of issue, or if you have added a rating, your present certificate will not have the original date of issue). Block 10. WORK EXPERIENCE (1) Complete the name, address, and telephone number of the employer/organization. (2) Job Title: Enter job title. (3) Dates Employed: Enter date employment began and date employment ended (i.e. 02–14–67 to 06–23–70). Use six-digit, numeric characters (i.e., 08–09–60); not August 9, 1960. (4) Supervisor’s Name: Enter the supervisor’s name(s). (5) Reason for leaving: Enter reason for leaving this position. (6) Description of Duties: Give a complete description of the duties performed during this period of employment. Block 11. LOCATION WHERE DESIGNEE FUNCTIONS WILL BE PERFORMED (DME and DPRE designees only). (1) Enter the address (including city, state, and Zip Code) where designee functions will be performed. (2) Enter the telephone number of this location (including area code). Block 11a. LOCAL FSDO OR IFO THAT MANAGES THIS AREA — From the list on page v enter the FSDO or IFO that has jurisdiction in the area or location where you will performing the designee duties. FAA Form 8110-28 (1-01) Supersedes Previous Edition ii i NSN: 0052-00-917-0001 American LegalNet, Inc. www.FormsWorkFlow.com Form Approved OMB No. 2120-0033 04/30/2010 Blocks 12 through 21. 1. All blocks must be answered “YES” or “NO.” Do not leave any block blank. All “YES” answers must be explained on an attached sheet of paper. Block 22. AWARDS PROGRAM — Complete this block by filling in the required items. Block 23. APPLICANT’S SIGNATURE — Sign and date the application after reading the statements in this block. Block 23a. TYPED OR PRINTED NAME OF APPLICANT – The applicant will type or print his or her name in this block of the application. FOR FAA OR NATIONAL EXAMINER BOARD USE ONLY Block 24. FOR ORIGINAL ISSUANCE ONLY — This block will be filled out by a representative of the National Examiner Board to record qualification and referral information. The NEB personnel will: (1) Check the qualified or not qualified block and enter date of determination. (2) If qualified and referred, indicate to which FSDO the applicant was assigned and enter date of referral. (3) The NEB representative will sign, list title, and date this portion when NEB action has occurred. Block 24a. DAR–T RECORD OF APPROVAL — This block will be filled out by the Principal Maintenance Inspector (PMI) representing the FSDO or IFO requesting a new designee and will indicate which functions the applicant is authorized to perform, and any limitations, in accordance with AC 183.35 latest revision, Airworthiness Designee Function Codes and Consolidated Directory for DMIR/DAR/ODAR/DAS/DOA and SFAR No. 36. Block 25. SIGNATURE AND DATE — The Regional Office will sign and date this block of the application. This responsibility may be delegated to the local FSDO or IFO. Block 26. DME/DPRE RECORD OF APPROVAL Block 26a. PMI FSDO OR IFO ACTION — Check the approve or disapprove box to indicate the selection status of each applicant’s files when the files are received from the NEB. Block 26b. REMARKS — Complete with any remarks that are appropriate. Block 26c. SIGNATURE AND DATE — The PMI will sign and date this block of the application. Block 26d. FSDO OR IFO MANAGER’S APPROVAL — The FSDO or IFO manager will check the approve or disapprove box to indicate concurrence or nonconcurrence of the selection of each applicant when files are forwarded by the PMI. Block 26e. REMARKS — Complete with any remarks that are appropriate. Block 26f. SIGNATURE AND DATE — The FSDO or IFO manager will sign and date this block of the application. NOTE: Blocks 27 through 27i are for renewals, reinstatements, and additional authorizations. Indicate by a check mark in the appropriate box if the application is for a renewal, reinstatement, or additional authorization. Block 27. FSDO OR IFO ACTIONS — The FSDO or IFO representative will check the box to indicate the type of action requested by the applicant. Block 27a. ORIGINAL CERTIFICATION VERIFICATION — Check Yes or No to indicate the designee continues to meet the original designation criteria. Block 27b. CRITERIA FOR ADDITIONAL AUTHORIZATION — The PMI will check the Yes or No box to indicate the applicant meets the criteria for the additional authorization sought. Block 27c. NEED FOR DESIGNEE —The PMI will indicate if there is still a need for the applicant’s service by checking Yes or No. Block 27d. INSPECTOR’S ACTION — The PMI will check the approve or disapprove box to indicate the applicant is or is not authorized for renewal, reinstatement, or additional authorization when the request is received from the applicant. Block 27e. REASON FOR DISAPPROVAL — The PMI will complete this block and list the reason(s) the applicant is not being approved for the designation sought. Block 27f. SIGNATURE AND DATE — The PMI will sign and date this block of the application. Block 27g. FSDO OR IFO MANAGER’S APPROVAL — The FSDO or IFO manager will check the approve or disapprove box to indicate concurrence or nonconcurrence of the action requested by each applicant when files are forwarded by the PMI. Block 27h. REASON FOR DISAPPROVAL — The FSDO or IFO manager will complete this block and list the reason(s) the applicant is not being approved for the designation sought. Block 27i. SIGNATURE AND DATE — The FSDO or IFO manager will sign and date this block of the application. NOTICE: Whoever in any matter w ithin the jurisdiction of any department or agency of the United States knowingly and willfully falsifies, conceal s, or covers up by any tr ick, schem e, or devi ce a material fact, or who makes any false, fictitious, or fraudulent statements or representations, or entry, may be fined up to $250,000 or imprisoned for not more than 5 years, or both. (18 U.S. Code Secs 1001;3571) FAA Form 8110-28 (1-01) Supersedes Previous Edition v i NSN: 0052-00-917-0001 American LegalNet, Inc. www.FormsWorkFlow.com Form Approved OMB No. 2120-0033 04/30/2010 LIST OF FLIGHT STANDARDS DISTRICT OFFICES �� WESTERN PACIFIC REGION (AWP) FAT HNL LAS LAX LGB OAK RAL FSDO-17 FSDO-13 FSDO-19 FSDO-23 FSDO-05 FSDO-27 FSDO-21 FRESNO, CA HONOLULU, HI LAS VEGAS, NV LOS ANGELES, CA LONG BEACH, CA OAKLAND, CA RIVERSIDE, CA SOUTHERN REGION EASTERN REGION (ASO) (AEA) GREAT LAKES REGION (AGL) ALT FSDO-11 COLLEGE PARK / ATLANTA, GA BHM FSDO-09 BIRMINGHAM, AL BNA FSDO-03 NASHVILLE, TN CAE FSDO-13 WEST COLUMBIA, SC FLL FSDO-17 FT. LAUDERDALE, FL TPA FSDO-35 TAMPA, FL ABE FRG AGC FSDO-05 ALLENTOWN, PA FSDO-11 FARMINGDALE, NY FSDO-03 WEST MIFFLIN / PITTSBURGH, PA ALB FSDO-01 ALBANY, NY BAL FSDO-07 BALTIMORE, MD CRW FSDO-09 CHARLESTON, WV CLE CMH CVG DPA DTW FAR GRR RNO FSDO-11 RENO, NV SAC FSDO-25 SACRAMENTO, CA SAN FSDO-09 SAN DIGEO, CA SDL FSDO-07 SCOTTSDALE, AZ INT JAN LOU MEM FSDO-05 WINSTON-SALEM, NC FSDO-07 JACKSON, MS FSDO-01 LOUISVILLE, KY FSDO-25 MEMPHIS, TN DCA FSDO-27 HAR FSDO-13 CHANTILLY, VA / WASHINGTON, DC NEW CUMBERLAND / HARRISBURG, PA IND FSDO-11 MKE FSDO-13 MSP FSDO-15 ORD FSDO-31 SJC FSDO-15 SAN JOSE, CA VNY FSDO-01 VAN NUYS, CA SFO FSDO-03 SAN FRANCISCO, CA MIA ORL CLT SJU TPA FSDO-19 FSDO-15 FSDO-33 FSDO-21 FSDO PHL FSDO-17 NYC FSDO-15 PIT FSDO-19 PHILADELPHIA, PA GARDEN CITY, NY CORAOPOLIS / PITTSBURGH, PA SANDSTON / RICHMOND, VA ROCHESTER, NY TEREBORO, NJ JAMAICA, NY RAP SBN SPI MIAMI, FL ORLANDO, FL CHARLOTTE, NC SAN JUAN, PR TAMPA, FL RIC FSDO-21 ROC FSDO-23 TEB FSDO-25 NY IFO-29 FSDO-25 FSDO-07 FSDO-05 FSDO-03 FSDO-23 FSDO-21 FSDO-09 FSDO-27 FSDO-17 FSDO-19 CLEVELAND, OH COLUMBUS, OH CINCINNATI, OH WEST CHICAGO, IL BELLEVILLE, MI FARGO, ND GRAND RAPIDS, MI INDIANAPOLIS, IN MILWAUKEE, WI MINNEAPOLIS, MN SCHILLER PARK, IL RAPID CITY, SD SOUTH BEND, IN SPRINGFIELD, IL SOUTHWEST REGION NEW ENGLAND REGION CENTRAL REGION ALASKAN REGION (ASW) (ANE) (ACE) (AAL) ABQ BTR DAL DWF FTW HOU LBB LIT OKC SAT FSDO-01 FSDO-03 FSDO-05 FSDO-07 FSDO-19 FSDO-09 FSDO-13 FSDO-11 FSDO-15 FSDO-17 ALBUQUERQUE, NM BATON ROUGE, LA DALLAS, TX DALLAS, TX FORT WORTH, TX HOUSTON, TX LUBBOCK, TX LITTLE ROCK, AR OKLAHOMA CITY, OK SAN ANTONIO, TX BED BDL BOS PWM FSDO-01 FSDO-03 FSDO-02 FSDO-05 BEDFORD, MA WINDSOR LOCKS, CT BOSTON, MA PORTLAND, ME DSM FSDO-01 DES MOINES, IA ICT FSDO-07 WICHITA, KS LNK FSDO-09 LINCOLN, NE MCI FSDO-05 KANSAS CITY, MO STL FSDO-03 ST. ANN / ST. LOUIS, MO NORTHWEST MOUNTAIN REGION (ANM) BOI CPR DEN GEG HLN PDX FSDO-11 FSDO-04 FSDO-03 FSDO-13 FSDO-05 FSDO-09 SEA SLC DEN FSDO-01 FSDO-07 FSDO-30 FAA Form 8110-28 (1-01) Supersedes Previous Edition ANC FSDO-03 FAI FSDO-01 JNU FSDO-05 ANCHORAGE, AK FAIRBANKS, AK JUNEAU, AK INTERNATIONAL FIELD OFFICE LIST BOISE, ID CASPER, WY DENVER, CO SPOKANE, WA HELENA, MT HILLSBORO / PORTLAND, OR SEATTLE, WA SALT LAKE CITY, UT DENVER, CO FRA SIN BRX LGW MIA FRANKFURT SINGAPORE BRUSSELS LONDON MIAMI SPRINGS, FL DFW IFO-SW23 DALLAS, TX v IFO-EA33 IFO-WP33 IFO-EA31 IFO-EA35 IFO-SO23 NSN: 0052-00-917-0001 American LegalNet, Inc. www.FormsWorkFlow.com Form Approved OMB No. 2120-0033 04/30/2010 Application and Statement of Qualification (DME/DPRE/DAR-T/ODAR-T) U.S. Department of Transportation Federal Aviation Administration This application is for: Yes Have you ever held a current or previous designation in any region? If "Yes" give designation number and dates: Renewal Expanded Authority Reinstatement Initial Application No Designation Number: From: To: 1. Name (Last, First, Middle) 3. Are You a U.S. Citizen? 2. Address (Apt No., Number, Street) No Yes 3a. If not a U.S. Citizen, Name the Country. 6. Phone No. 3b. DAR-T Repairman Repair Station Number(s) Zip State City 5. Date of Birth (MonthlDaylYear) 4. Social Security Number Home: Work: 7a. Your Flight Standards District Office (FSDO) or International Field Office (IFO) of jurisdiction? 7. Designation Sought (Check appropriate box(es) below:) Designated Mechanic Examiner (DME) Airframe Powerplant Seat Designated Parachute Rigger Examiner (DPRE) Airframe and Powerplant Back Chest Lap Designated Airworthiness Representative (DAR-T) (Maintenance Function(s) only) Organizational Designated Airworthiness Representative (ODAR-T) (Maintenance Function(s) only) 7b. DAR-T/ODAR-T applicants shall list specific function codes requested from those identified in AC 183-35 and/or FAA Order 8100.8 (Maintenance Only). 8. Did you graduate from high school or have a GED high school equivalency? Yes If "YES" give month and year of graduation. No If "NO" give the highest grade completed. College and/or Technical Training Dates From: MM - DD -YY To: MM - DD -YY Degree or Certificate Received Curriculum or Study Program Name of School 9. FAA Certificates Held Pertinent to Designation Sought Rating Certificate Number Type Original Date of Issue 10. Work Experience: Describe all work experience that pertains to your qualifications for the designation sought. Describe your current or most recent work experience in Block A and work backwards, describing each applicable position you have held during at least the past 5 years. You may describe work experience accrued more than 5 years ago if you wish to do so. Use a separate block for each position described. Include military service if your military experience is pertinent to your application for a designation. A. Name of Employer/Organization: Telephone No. Address Job Title: Zip State City Dates Employed: From: Supervisor's Name: To: Reason for Leaving: Description of Duties (Use blank sheet of paper if more space is needed.) B. Name of Employer/Organization: Telephone No. Address Job Title: Zip State City Dates Employed: From: Supervisor's Name: To: Reason for Leaving: FAA Form 8110-28 (I -0 1) Supersedes Previous Edition 1 NSN: 0052-00-917-0001 American LegalNet, Inc. www.FormsWorkFlow.com Form Approved OMB No. 2120-0033 04/30/2010 Description of Duties: (Use blank sheet of paper if more space is needed.) C. Name of Employer/Organization: Telephone No. Address Zip State City Job Title: Dates Employed: Supervisor's Name: From: To: Reason for Leaving: Description of Duties: (Use blank sheet of paper if more space is needed.) D. Name of Employer/Organization: Telephone No. Address Zip State City Job Title: Dates Employed: Supervisor's Name: From: To: Reason for Leaving: Description of Duties: (Use blank sheet of paper if more space is needed.) E. Name of Employer/Organization: Telephone No. Address City Zip State Job Title: Dates Employed: Supervisor's Name: From: To: Reason for Leaving: Description of Duties: (Use blank sheet of paper if more space is needed.) 11. Location Where Designee Functions Will Be Performed: (DME or DPRE ONLY) Address Telephone No. City, State and Zip Code 11a. FSDO or IFO that manages the area where authorized functions will be performed: 12. During the last 5 years were you fired from any job? Yes 14. Are you now under charges for any violation of law? 13. Have you ever been convicted of any felony violation? Yes No No 16. Have you ever been convicted by a military court­ martial? Yes Yes Yes 17. Have you ever been discharged from the military service under a General Discharge? No 15. Have you ever been imprisoned, been on probation, or been on parole? No Yes 18. Have you ever been discharged from a military service under other than Honorable Conditions? No Yes No No 19. Has any certificate issued to you ever been revoked? Yes No 20. Have you ever been convicted of, or are you now under charges for, violation of Federal, State, or Local statutes relating to narcotic drugs, marijuana, Yes No depressants, or stimulant drugs or substances? 21. Give full details regarding each question in blocks 12 through 19 to which you have answered ''Yes.'' (Use blank sheet of paper if more space is needed.) FAA Form 8110-28 (I -0 1) Supersedes Previous Edition 2 NSN: 0052-00-917-0001 American LegalNet, Inc. www.FormsWorkFlow.com Form Approved OMB No. 2120-0033 04/30/2010 Yes 22. Have you ever participated in the Maintenance Technician Award Program? No If yes, list the latest year you participated. Phase I - Bronze Phase II - Silver Phase IV - Ruby Check which Phase: Phase III - Gold Phase V - Diamond Remarks: SIGNATURE, RELEASE OF INFORMATION, AND CERTIFICATION-Read Carefully YOU MUST SIGN AND DATE THIS APPLICATION - (You must print or type your name under the signature block) I understand that a false statement on any part of this application will be grounds for not approving this application, for rescinding my eligibility as an examiner or designee candidate, for not designating me, or for terminating any designation I may receive. I understand that any information I give may be investigated. I consent to the release of information regarding my personal and technical qualifications for designation as a mechanic examiner/parachute rigger examiner/ designated airworthiness representative-maintenance/or organizational designated representative-maintenance by employers, schools, law enforcement agencies, and other individuals and organizations, to investigators, employees of the federal government, and persons not employed by the federal government to whom the Federal Aviation Administration (FAA) has delegated the authority to screen and approve or disapprove DME/DPRE/DAR-T/ODAR-T applicants. I understand that, if my application is accepted, approval for assignment to the national examiner/designee candidate pool is dependent on satisfactory completion of the predesignation knowledge test with a score of 80 percent or higher for DME/DPRE. I understand that assignment to the national examiner/designee candidate pool does not guarantee selection or designation as a mechanic examiner/parachute rigger examiner/or designated airworthiness representative maintenance and that, if selected, designation is dependent upon satisfactory completion ofa practical test (demonstration of competency) for DME/DPRE and satisfactory completion of the Initial Technical Airman Examiner Standardization Seminar for DME/DPRE/DAR-T candidates. I understand that my FAA accident/incident violation history will be verified at each stage of the application process. I understand that designation as a mechanic examiner/parachute rigger examiner/designated airworthiness representative-maintenance/organizationaI designated airworthiness representative-maintenance is a privilege, not a right, and that any designation received may be terminated, revoked, or not renewed at any time or for any reason the FAA Administrator deems appropriate. I certify that, to the best of my knowledge and belief, all of my statements on this application are true, correct, complete, and in good faith. Notice: Whoever in any matter within the jurisdiction of any department or agency of the United States Knowingly and willfully falsifies, conceals, or covers up by any trick, scheme, or device a material fact, or who makes any false, fictitious, or fraudulent statements of representations, or entry, may be fined up to $250,000 or imprisoned for not more than 5 years, or both. (18 U.S. Code Secs 1001;3571) 23. Signature of Applicant Date signed (Month, Day, Year) 23a. Typed or Printed Name of Applicant FOR NATIONAL EXAMINER BOARD USE ONLY 24. (For Original Issuance Only) Qualified Not Qualified Referred to: Date: FSDO Signature of NEB Official: Date: Title: Date: INITIAL SELECTION - FOR FAA (FSDO, RO, OR IFO) USE ONLY. BLOCKS 24A-26F 24a. DAR-T RECORD OF APPROVAL Designated Airworthiness Representative Maintenance Function(s) NOTE: A separate approval is required for each discipline. Function(s) Authorized (Identify speciflefunction(s) authorized including any limitations). 25. Regional Office Signature of Approval DAR/ODAR Only Approve Regional Office Signature FAA Form 8110-28 (1-01) Supersedes Previous Edition Disapprove Date 3 NSN: 0052-00-917-0001 American LegalNet, Inc. www.FormsWorkFlow.com Form Approved OMB No. 2120-0033 04/30/2010 Designated Mechanic Examiner 26. DME/DPRE RECORD OF APPROVAL APPROVE 26a. FSDO or IFO Principal Maintenance Inspector's Action: Designated Parachute Rigger Examiner DISAPPROVE 26b. Remarks: DATE: 26c. Principal Maintenance Inspector's Signature: APPROVE 26d. Managing FSDO or IFO Manager's Action: DISAPPROVE 26e. Remarks: 26f. Managing FSDO or IFO Manager Signature: 27. FSDO or IFO Actions: DATE: Renewal Reinstatement Additional Authorization 27a. The examiner continues to meet the criteria for the original designation Yes No 27b. The examiner meets the criteria for the additional authorization sought Yes No 27c. There is a need for the examiner's services 27d. Inspector's Action: APPROVE Yes No DISAPPROVE 27e. Reason for Disapproval (Use blank sheet of paper if more space is needed) 27f. Principal Maintenance Inspector's Signature: 27g. Manager's Action: APPROVE DATE: DISAPPROVE 27h. Reason for Disapproval (Attach additional sheets, if required.) 27i. Managing FSDO or IFO Manager Signature: FAA Form 8110-28 (1-01) Supersedes Previous Edition DATE: 4 NSN: 0052-00-917-0001 American LegalNet, Inc. www.FormsWorkFlow.com