U.S. Department of Transportation Federal Aviation Administration INFORMATION FOR APPLICANT Application For An Airman Certificate and/or Rating Privacy Act Statement Information requested on this form is solicited under the authority of Title 49 of the United StatesCode(Transportation)sections109(9), 40113(a), 44701-44703, and 44709 (1994), formerly codified in the Federal Aviation Act of 1958, as amended, and Title 14 of the Code of Federal Regulations (CFR), Part 67, Medical Standards and Certification. Submission of this information is mandatory and incomplete submission will result in delay of consideration or denial of application for an airman medical certificate. The purpose of this information is to determine whether an applicant meets Federal Aviation Administration medical requirements to hold an airman medical certificate for further consideration under 14 CFR 11.53 and 67.401. It is also used to depict airman population patterns and to update certification procedures and medical standards. The information collected on this form becomes a part of the Privacy Act System of Records DOT/FAA 847, General Air Transportation Records on Individuals, and is provided the protection outlined in the system's description as published in the Federal Register. Paperwork Reduction Act Statement: The information collected on this form is necessary to determine applicant eligibility for flight engineer or flight navigator certificates. The information is used to determine certification eligibility. We estimated that it will take 6 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, 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 2120-0007. 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 Tear off this cover sheet before submitting this form. FAA Form 8400-3 (1-98) Supersedes Previous Edition Electronic Version (Adobe) NSN: 0052-00-692-3002 American LegalNet, Inc. www.FormsWorkflow.com Form Approved OMB NO. 2120-0007 01/31/2008 U.S. Department of Transportation Federal Aviation Administration Application For An Airman Certificate and/or Rating Flight Navigator Control Tower Operator VFR Tower Rating Non-Radar Approach Control Tower Rating 2. TIME IN THIS AIRCRAFT 3. NAME OF EMPLOYER Flight Engineer Reciprocating Engine Powered Turbopropeller Powered Turbojet Powered 1. TYPE OF AIRCRAFT TO BE USED 4. Applicant Identification A. NAME (First, Middle, Last) B. SOCIAL SECURITY NO. F. HAIR G. EYES H. SEX Aircraft Dispatcher Reissuance of Certificate Additional Rating K. PERMANENT MAILING ADDRESS (Include Zip Code) I. NATIONALITY TELEPHONE NO. J. PLACE OF BIRTH 5. Certificates Held by Applicant A. Pilot Airline Transport Commercial Flight Instructor Private B. Flight Navigator C. Control Tower Operator D. Flight Engineer E. Ground Inspector F. Aircraft Dispatcher G. Mechanic 6. Applicant's Certification I certify that I meet all pertinent requirements of the Regulations for the certificate or rating applied for Instructor's Recommendation 7. I consider the above applicant ready to take the test for which he/she is applying: D. Date Instructor's Signature Date Applicant's Signature A. Oral Test B. Flight or C. Practical Test Aircraft Dispatcher Instructor's Certificate No. & Expiration Grade & Certificate No. Date Instructor's Certificate No. & Expiration Grade & Certificate No. Date E. Date Instructor's Signature 8. Evaluation Record Oral Practical Test Aircraft Dispatcher Practical Test Control Tower Operator Simulator Check Aircraft Flight Check 9. Inspector's Record Temporary Airman Certificate Issued Notice of Disapproval of Application Issued Examiner's Action Accepted Inspector Examiner Signature Date DATE CP REQ. OFFICE COM ISS INSPECTOR'S SIGNATURE ACT EMP TRN M.T. DIS CLASS SEX RATING STATE FAA OFFICE COUNTY Aircraft Dispatcher Special Mailing Airmail IFO Mailing Correspondence FAA Form 8400-3 (1-98) Supersedes Previous Edition Electronic Version (Adobe) NSN: 0052-00-692-3002 American LegalNet, Inc. www.FormsWorkflow.com 10. Practical Test Report Grading Legend (All applicable items must be graded S or U) Explain in ''Remarks'' all items which are not graded. S-Satisfactory, U-Unsatisfactory Grade Item No. Item No. Examiner Inspector A. Flight Engineer C. Aircraft Dispatcher Form Approved OMB NO. 2120-0007 01/31/2008 Grade Examiner Grade Item No. Examiner NSN: 0052-00-692-3002 American LegalNet, Inc. www.FormsWorkflow.com 1 2 3 4 5 6 7 8 9 10 11 Item No. Equipment Examination (Oral) Preflight Inspection Normal Operating Procedures Abnormal Operating Procedures Performance Data and Cruise Control Trouble Shooting Emergency Procedures Forms and Records Post Flight Crew Coordination Judgement Grade B. Flight Navigator Examiner Inspector 1 2 3 4 5 6 7 Aircraft Air Routes and Airports Altimeters Weather Analysis Airman's Information Manual Dispatch and Assistance Emergency Procedures Inspector D. Control Tower Operator VFR TOWER RATING 1 2 3 4 5 6 The Control Tower The Airport The Control Zone Notice to Airmen Weather Facilities and Procedures A Demonstration of Ability to Control Air Traffic Under VFR NON-RADAR APPROACH CONTROL TOWER RATING Air Traffic Control Facilities Air Navigation Facilities Use of Airman's Information Manual Holding Procedures Approach Procedures Missed Approach Facilities Alternate Airports Search and Rescue Procedures A Demonstration of Ability to Control Air Traffic Under IFR Airport Identification 1 2 3 4 5 6 7 8 9 10 Equipment (Oral) Equipment Check Preflight Training Normal Navigation Procedures Knowledge of Navigation Methods Co-ordination of Navigational Methods Emergency Procedures Co-ordination of Duties Crew Coordination Judgement From To Hours Day Night 1 2 3 4 5 6 7 8 9 10 11. Route of Flight Check Airmans Identification (ID) Form of ID Number Expiration Date 10. Remarks FAA Form 8400-3 (1-98) Supersedes Previous Edition Electronic Version (Adobe) Inspector