Form Approved OMB No. 2120-0690 07/31/2007 LIGHT-SPORT STANDARDIZATION BOARD—DESIGNATED PILOT EXAMINER CANDIDATE APPLICATION Supplemental Information and Instructions U.S. Department of Transportation Federal Aviation Administration Privacy Act Statement The information on the accompanying form is solicited under authority of the Public Law 103-272, dated July 5, 1994. The purpose of this information is to determine your eligibility for designation as a pilot examiner. The information will become part of the Privacy Act system of records DOT / FAA 830, Representatives of the Administrator, and will be used to evaluate your qualifications for designation as a pilot examiner. Submission of all data is mandatory except for Social Security Number (SSN), which is voluntary. If you do not disclose your SSN, a unique number will be assigned to your file. Your application cannot be processed unless the information is complete. Paperwork Reduction Act Statement The information is necessary to determine your eligibility to become a pilot examiner. It is estimated that it will take approximately 55 minutes per response. The information will become part of the Privacy Act system of records, DOT / FAA 830, Representatives of the Administrator, and it will be used to evaluate your qualifications for appointment as a designated pilot examiner. It should be noted that 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 of information is 2120-0690. 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. LIGHT-SPORT STANDARDIZATION BOARD — DESIGNATED PILOT EXAMINER CANDIDATE APPLICATION HOW TO APPLY—(Initial Designations) • Answer all applicable questions (blocks) fully. • Refer to the attached instruction sheets if you require assistance to answer a question (block). • Complete, sign, and date this application in black ink. • If you need more space to answer a question (block), use additional sheets of blank paper. Be sure to indicate the question (block) number and your name at the top of each additional sheet. • Attach a copy (front and back) of all applicable pilot, flight instructor, and either an airman medical certificate or valid US Drivers License to this application. • Remove all instruction sheets before you send in your completed application. • Be sure to keep a completed copy of the application and all additional sheets for your files. WHERE TO SEND APPLICATION— Federal Aviation Administration Light-Sport Aviation Branch (AFS-610), ATTN: Light-Sport Standardization Board, P.O. Box 25082, Oklahoma City, OK 73125-0082 WHAT HAPPENS TO YOUR APPLICATION— The Light-Sport Standardization Board (LSSB) will evaluate your application to ensure that you meet the selection criteria for the designation(s) sought. The LSSB will advise you, in writing, whether or not you meet the applicable selection criteria. If the LSSB sends you a letter stating you do NOT meet the selection criteria, do NOT take the predesignation knowledge test. If the LSSB sends you a letter stating you do meet the selection criteria, you will be directed to take the examiner predesignation knowledge test appropriate to the designation(s) sought. For example: airplane, weight-shift control, gyroplane, glider, powered parachute, airship and balloon. You may take the examiner predesignation knowledge test at any FAA-approved computerized testing center. Request the pilot examiner predesignation knowledge test for the category applicable to the designation(s) sought. You MUST forward the original test results to the LSSB within 10 days of the date you take the examiner predesignation knowledge test. Keep a copy of the test results for your personal records. Upon receiving your original test results with a score of 80 percent or higher, the LSSB will notify you of approval or disapproval for assignment to the national examiner candidate pool. The LSSB will forward only the top three ranking candidates within the national examiner candidate pool to AFS-610 when they request a new designee. The LSSB keeps your application in the national examiner candidate pool for 2 years or until AFS­ 610 selects you, whichever comes first. After 2 years, the LSSB will delete the applications of all candidates not selected from the national examiner candidate pool. An applicant must repeat the application process in order to apply for reassignment to the national examiner candidate pool. FAA Form 8710-12 (9-04) i American LegalNet, Inc. www.FormsWorkflow.com Form Approved OMB No. 2120-0690 07/31/2007 LIGHT-SPORT STANDARDIZATION BOARD—DESIGNATED PILOT EXAMINER CANDIDATE APPLICATION Supplemental Information and Instructions (Continued) TYPES OF DESIGNATIONS AND DESIGNEE DEFINITIONS— SPE - Sport Pilot Examiner Sport Pilot Flight Instructor Examiner SFIE GENERAL QUALIFICATIONS— • The applicant must hold all pertinent category and classes for each aircraft for which designation is sought. • The applicant must hold a valid third-class airman medical certificate or valid U. S. driver’s license for initial designation. (A medical certificate or U. S. driver’s license is NOT required for designations limited to examining in balloons and gliders.) • The applicant must be at least 21 years old. • The applicant must have a good record as a pilot and flight instructor with regard to accidents, incidents, and violations. • The applicant must meet all eligibility and experience requirements for the specific designation sought in accordance with the table on page iv and the appropriate FAA orders and handbooks. • The applicant must have a reputation for integrity and dependability in the industry and the community. • The applicant must have a history of a harmonious relationship with the FAA. INSTRUCTIONS FOR COMPLETING FAA FORM 8710-11— 1. All entries on FAA Form 8710-11 must be made in black ink or typewritten. 2. Read the attached "Privacy Act Statement." 3. Complete blocks 1 through 33: a. Block 1. Name (Last, First, Middle)— (1) Enter your legal name. For record purposes, do not use more than one middle name. (2) If you do not have a 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. b. Block 2. Social Security Number— (1) Completing Block 2 is optional (see "Privacy Act Statement"). (2) Enter your Social Security Number or one of the following: "DO NOT USE" or "NONE." c. Block 2A. Date of Birth—Enter date using eight-digit, numeric characters (e.g., 09/09/1959 not September 9, 1959). d. Block 3. Permanent Mailing Address—Enter all required information, to include number and street, P.O. Box, City, State, and Zip Code. e. Block 4. Telephone Number—Enter your home and business telephone numbers including the area code and extensions, if applicable. You may also enter your Fax number, if applicable. f. Block 5. This application is for:—Initial Application for LSSB, Renewal Application for LSSB, or Reinstatement for LSSB. Check the box to the left of the reason for this application. NOTE: Reinstatements are NOT to be sent to the LSSB they should be sent to AFS-610. g. Block 6. Have you ever held an FAA pilot examiner designation in any region?—(If "YES," enter the date(s) and the supervising FSDO.) h. Block 7. Type of designation(s) sought:—Check the box to the left of the designation(s) sought. Sport Pilot Examiner (SPE), Sport Pilot Flight Instructor Examiner (SFIE). (See the SPECIFIC ELIGIBILITY REQUIREMENTS criteria shown on page iv.) i. Block 8. Check the box to the left of the category/class of aircraft for which authorization is sought.—Self-explanatory. j. Block 9. Enter the FSDO (page iv) in the area where you desire to serve. k. Block 10. Enter the names of other FSDO (page iv) areas you can provide examiner service on a regular basis, if any. l. Block 11. Has any certificate or rating issued to you ever been revoked?—(If "YES," describe the circumstances.) m. Block 12. Have you had any aircraft accidents or incidents within the past 5 years?—(If "YES," describe the circumstances.) n. Block 13. Are you a U.S. citizen?—(You must enter "YES" or "NO.") NOTE: You are not required to be a U.S. citizen in order to be a designated examiner. o. Block 14. If you are NOT a U.S. citizen, enter the country in which you hold citizenship. If you hold dual citizenship, indicate the names of both countries.—Self-explanatory. p. Block 15. Do you read, write, speak, and understand English fluently?—Self-explanatory. q. Block 16. FAA certificates held— Provide Pilot/Instructor certificates held, their certificate numbers, and their ratings and limitations as shown on the certificate. NOTE: You must provide copies (front and back) of all certificates. r. Block 17. Enter all of your special training that is pertinent to the designation sought.—Self-explanatory. s. Block 18A. Have you ever served as a chief or assistant chief instructor in a school authorized under Title 14 of the Code of Federal Regulations (14 CFR) part 141?—(If "YES," enter the date(s).) Block 18B. Have you ever served as a check airman authorized under Title 14 of the Code of Federal Regulations (14 CFR) part 121 and/or part 135?—(If "YES," enter the date(s) and the FSDO.) FAA Form 8710-12 (9-04) ii American LegalNet, Inc. www.FormsWorkflow.com Form Approved OMB No. 2120-0690 07/31/2007 — LIGHT-SPORT STANDARDIZATION BOARD—DESIGNATED PILOT EXAMINER CANDIDATE APPLICATION Supplemental Information and Instructions (Continued) v. w. x. y. z. aa. bb. cc. dd. ee. ff. gg. hh. ii. jj. Block 18C. Have you ever been an FAA Aviation Safety Inspector?—(If "YES," enter the date(s) and the FSDO.) Block 18D. Have you ever been an Instructor for a FAA accredited Exemption Holder?—(If "YES," enter the Exemption Name) Block 18E. Have you been Recommended by a FAA accredited Exemption Holder? — Attach Letter of Recommendation Block 19. Have you ever been a military pilot evaluator?—(If "YES," enter the date(s).) Block 20. Have you ever been an FAA Accident Prevention Counselor or FAA Aviation Safety Counselor?—(If "YES," enter the date(s) and the FSDO.) Block 21. Flight Experience—Enter all your actual flight time (in hours), as requested. Do not round off or approximate your hours (i.e., ±). Answer Blocks 21A through 21C, if applicable. (See the SPECIFIC ELIGIBILITY REQUIREMENTS criteria shown on page iv.) Block 22. Work Experience—Describe your current or most recent work experience in Block 22A and work backwards. Use a separate block for each position described (e.g., Block 22A, Block 22B, etc.). Describe all of your work experience in specific detail that pertains to your qualifications for the designation(s) sought. Describe each applicable position you held during at least the past 5 years. You may describe work experience accrued more than 5 years ago. Include military service if your military experience is pertinent to your application for an examiner designation. (1) Complete the name, address, and telephone number of the employer/organization. (2) Job Title: Self-explanatory. (3) Dates Employed: Enter the dates of employment. (4) Supervisor's Name: Self-explanatory. (5) Reason for Leaving: Self-explanatory. (6) Description of Duties: Enter a complete description of the duties performed during this period of employment. Block 23. Briefly summarize your aviation activities and professional responsibilities that best qualify you to be a designated pilot examiner.—Self-explanatory. Block 24. During the past 5 years, were you fired from any job for any reason?—NOTE: If you answer "YES," you MUST enter the full details in Block 31. Block 25. Have you ever been convicted of any felony violation?—NOTE: If you answer "YES," you MUST enter the full details in Block 31. Block 26. Are you now under charges for any violation of law?—NOTE: If you answer "YES," you MUST enter the full details in Block 31. Block 27. Have you ever been imprisoned, been on probation, or been on parole?—NOTE: If you answer "YES," you MUST enter the full details in Block 31. Block 28. Have you ever been convicted by a military court-martial?—NOTE: If you answer "YES," you MUST enter the full details in Block 31. Block 29. Have you ever been discharged from a military service under a General discharge?—NOTE: If you answer "YES," you MUST enter the full details in Block 31. Block 30. Have you ever been discharged from a military service under other than honorable conditions?—NOTE: If you answer "YES," you MUST enter the full details in Block 31. Block 31. If you answered "YES" to any questions in Blocks 24 through 30, you MUST enter the full details. Block 32. Education and Training—Are you a high school graduate? (If "YES," enter the name of the high school and the date you graduated.) Are you a GED graduate? (If "YES," enter the date you received the GED.) (1) College and/or Technical Training Dates: Enter the beginning and ending dates of the training that you attended. (2) Name of School: Enter the name of the school(s) you attended. (3) Curriculum or Study Program: Enter the curriculum or study program for each school(s) listed. (4) Degree or Certificate Received: Enter degrees or certificates you received from each school(s) listed. Block 33. Applicant's Signature—After you read the "RELEASE OF INFORMATION AND CERTIFICATION STATEMENT" and the "NOTICE," sign the application, in black ink. After you sign your name, print or type your name under your signature. Enter the date you signed the application using eight-digit, numeric characters (e.g., 01/05/2004 not January 5, 2004). FAA Form 8710-12 (9-04) iii American LegalNet, Inc. www.FormsWorkflow.com Form Approved OMB No. 2120-0690 LIGHT-SPORT STANDARDIZATION BOARD—DESIGNATED PILOT EXAMINER CANDIDATE APPLICATION Supplemental Information and Instructions (Continued) FLIGHT STANDARDS DISTRICT OFFICES ALASKAN REGION (AAL) ANCHORAGE, AK FAIRBANKS, AK JUNEAU, AK GREAT LAKES REGION (AGL) 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 CENTRAL REGION (ACE) DES MOINES, IA WICHITA, KS LINCOLN, NE KANSAS CITY, MO ST. ANN / ST. LOUIS, MO EASTERN REGION (AEA) ALLENTOWN, PA FARMINGDALE, NY W. MIFFLIN PA PITTSBURGH, PA ALBANY, NY BALTIMORE, MD CHARLESTON, WV CHANTILLY, VA WASH, DC NEW CUMBERLAND PA HARRISBURG, PA PHILADELPHIA, PA GARDEN CITY, NY PITTSBURGH, PA RICHMOND, VA ROCHESTER, NY TETERBORO, NJ JAMAICA, NY NEW ENGLAND REGION (ANE) BEDFORD, MA WINDSOR LOCKS, CT BOSTON, MA PORTLAND, ME SOUTHERN REGION (ASO) COLLEGE PARK, GA ATLANTA, GA BIRMINGHAM, AL NASHVILLE, TN WEST COLUMBIA, SC FT. LAUDERDALE, FL TAMPA, FL WINSTON-SALEM, NC JACKSON, MS LOUISVILLE, KY MEMPHIS, TN MIAMI, FL ORLANDO, FL CHARLOTTE, NC SAN JUAN, PR TAMPA, FL SOUTHWEST REGION (ASW) ALBUQUERQUE, NM BATON ROUGE, LA DALLAS, TX FT. WORTH, TX HOUSTON, TX LUBBOCK, TX LITTLE ROCK, AR OKLA. CITY, OK SAN ANTONIO, TX WESTERN PACIFIC REGION (AWP) FRESNO, CA HONOLULU, HI LAS VEGAS, NV LOS ANGELES, CA LONG BEACH, CA OAKLAND, CA RIVERSIDE, CA RENO, NV SACRAMENTO, CA SAN DIEGO, CA SCOTTSDALE, AZ SAN JOSE, CA VAN NUYS, CA SAN FRANCISCO, CA NORTHWEST MOUNTAIN REGION (ANM) BOISE, ID CASPER, WY DENVER, CO SPOKANE, WA HELENA, MT HILLSBORO, OR PORTLAND, OR SEATTLE, WA SALT LAKE CITY, UT DENVER, CO SPECIFIC ELIGIBILITY REQUIREMENTS FOR SPORT PILOT EXAMINER DESIGNEES Category of Light Sport Aircraft Applied For: PIC Total PIC In LSA Category Total Flight Instruction Given Total Flight Instruction Given In LSA Category PIC Last 12 Months In LSA Category Total Flight Instruction Given in Last 12 Months Airplane 500 250 200 100 50 N/A Powered Parachute 250 100 100 50 25 N/A Weight Shift Control 500 250 200 100 50 N/A Gyroplane 500 250 * 200 200 * 50 * N/A Glider 250 100 * 100 50 * 10 HRS * 10 FLTS * N/A Airship 200 100 * N/A 100 * 20 * N/A Balloon 200 100 * N/A 50 * 20 HRS * 10 FLTS * 10 * Note: Not required to be in Light Sport Aircraft for this category. FAA Form 8710-12 (9-04) iv American LegalNet, Inc. www.FormsWorkflow.com Form Approved OMB No. 2120-0690 07/31/2007 LIGHT-SPORT STANDARDIZATION BOARD—DESIGNATED PILOT EXAMINER CANDIDATE APPLICATION U.S. Department of Transportation Federal Aviation Administration 1. Name (Last, First, Middle)— 3. Permanent Mailing Address— City: 5. This application is for:—


Initial Application for LSSB Renewal Application for LSSB Reinstatement (other than initial designation) for LSSB 2. Social Security Number— 2A. Date of Birth— 4. Telephone Numbers— Home Phone: ( ) State: Zip Code: Business Phone: ( ) Fax Number: ( ) 7. Type of designation(s) sought:— 6. Have you ever held an FAA pilot examiner designation in any region?— (If "Yes," enter the date(s) and the supervising
SPE - Sport Pilot Examiner FSDO.)
SFIE ­ Sport Pilot Flight Instructor Examiner
YES
NO From (mo/yr):____________ To (mo/yr):______________ FSDO:__________________ Airplane Land 9. Enter the FSDO area (s) where your desire to serve. — ____________________________________ 10. Enter the names of other FSDO areas you can provide examiner service on a regular basis, if any.— ______________________________________________ Airplane Sea ____________________________________ ______________________________________________ Powered Parachute Sea ____________________________________ ______________________________________________ Weight Shift Control Land ____________________________________ ______________________________________________ Gyroplane ____________________________________ ______________________________________________ Glider ____________________________________ ______________________________________________ ____________________________________ ______________________________________________ 8. Check the category/class of aircraft for which authorization is sought.—









Powered Parachute Land Weight Shift Control Sea Airship Balloon 11. Has any certificate or rating issued to you ever been revoked?— (If "YES," describe the circumstances.) 12. Have you had any aircraft accidents or incidents within the past 5 years?— (If "YES," describe the circumstances.)
YES
NO __________________________________________________________
YES
NO _______________________________________________________________ __________________________________________________________ _______________________________________________________________ __________________________________________________________ _______________________________________________________________ __________________________________________________________ _______________________________________________________________ __________________________________________________________ _______________________________________________________________ 13. Are you a U.S. citizen?—
YES
NO 14. If you are NOT a U.S. citizen, enter the country in which you hold citizenship. If you hold dual citizenship, indicate the names of both countries.— ____________________________________ 15. Do you read, write, speak, and understand English fluently?—
YES
NO 16. FAA certificates held—You MUST provide copies (front and back) of all certificates. Attach a separate sheet of paper. 17. Enter all of your special training, which is pertinent to the designation sought.— __________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________ FAA Form 8710-12 (9-04) 1 American LegalNet, Inc. www.FormsWorkflow.com Form Approved OMB No. 2120-0690 18A. Have you ever served as a chief or assistant chief instructor in a school authorized under Title 14 of the Code of Federal Regulations (14 CFR) part 141?— (If "YES," enter the date(s).)
YES
NO From (mo/yr):_____________ To (mo/yr):_____________ 18B. Have you ever served as a check airman authorized under Title 14 of the Code of Federal Regulations (14 CFR) part 121 and/or part 135?— (If "YES," enter the date(s) and the FSDO.)
YES
NO From (mo/yr):_____________ To (mo/yr):_____________ FSDO:____________________________________ 18C. Have you ever been an FAA Aviation Safety Inspector?—(If "YES," enter the date(s) and the FSDO.)
YES
NO From (mo/yr):_____________ To (mo/yr):_____________FSDO:_________________________________________ 18D. Have you ever been an Instructor for a FAA accredited Exemption Holder? —
YES
NO From (mo/yr):_____________ To (mo/yr):_____________ Exemption :_________________________________________ 18E. Have you ever been Recommended by a FAA accredited Exemption Holder? — Attach Letter of Recommendation
YES
NO Exemption :_________________________________________ 19. Have you ever been a military pilot evaluator?—(If "YES," enter the date(s).)
YES
NO From (mo/yr):_____________ To (mo/yr):_____________ 20. Have you been an FAA Accident Prevention Counselor or FAA Aviation Safety Counselor?—(If "YES," enter the date(s) and the FSDO.)
YES
NO From (mo/yr):_____________To (mo/yr):_______________FSDO:___________________________________________ 21. Flight Experience—Enter all your actual flight time (in hours), as requested. Do not round off or approximate your hours (i.e., ±). Do not write in the shaded areas. Answer Blocks 21A through 21C, if applicable. NOTE: See FAR part 1 for Light-Sport Aircraft definition. (See the SPECIFIC ELIGIBILITY REQUIREMENTS criteria shown on page iv.) Aircraft Experience PIC Total PIC Light-Sport Aircraft Total Flight Instruction Given In LightSport Aircraft Total Flight Instruction Given PIC Last 12 Months In Light-Sport Aircraft Total Flight Instruction Given in Last 12 Months Airplane Land Airplane Sea Powered Parachute Land Powered Parachute Sea Weight-Shift Control Land Weight-Shift Control Sea Gyroplane HRS HRS FLTS Glider F LTS Airship H RS Balloon FLTS 21B. Enter number of balloon flights as PIC that were at least 30 minutes duration within the past year.—______________________________________________ FAA Form 8710-12 (9/04) 2 American LegalNet, Inc. www.FormsWorkflow.com Form Approved OMB No. 2120-0690 21C. Enter number of pilot and/or flight instructor certification practical tests completed within the past year (as FAA Aviation Safety Inspector).—_____________ 22. Work Experience—Describe your current or most recent work experience in Block 22A and work backwards. Use a separate block for each position described (e.g., Block 22A, Block 22B, etc.). Describe all of your work experience in specific detail that pertains to your qualifications for the designation(s) sought. Describe each applicable position you held during at least the past 5 years. You may describe work experience accrued more than 5 years ago. Include military service if your military experience is pertinent to your application for an examiner designation. 22A. Name of Employer/Organization: Telephone N umber ( Address: City: Job Title: Reason for Leaving: ) State: Dates Employed (mo/yr): From: To: Zip Code: Supervisor's Name: Description of Duties: 22B. Name of Employer/Organization: Telephone N umber ( Address: City: Job Title: Reason for Leaving: ) State: Dates Employed (mo/yr): From: To: Zip Code: Supervisor's Name: Description of Duties: 22C. Name of Employer/Organization: Telephone N umber ( Address: City: Job Title: Reason for Leaving: State: Dates Employed (mo/yr): From: To: ) Zip Code: Supervisor's Name: Description of Duties: FAA Form 8710-12 (9-04) 3 American LegalNet, Inc. www.FormsWorkflow.com Form Approved OMB No. 2120-0690 22D. Name of Employer/Organization: Telephone N umber ( Address: City: Job Title: Reason for Leaving: ) State: Dates Employed (mo/yr): From: To: Zip Code: Supervisor's Name: Description of Duties: 22E. Name of Employer/Organization: Telephone N umber ( Address: City: Job Title: Reason for Leaving: ) State: Dates Employed (mo/yr): From: To: Zip Code: Supervisor's Name: Description of Duties: 22F. Name of Employer/Organization: Telephone N umber ( Address: City: Job Title: Reason for Leaving: State: Dates Employed (mo/yr): From: To: ) Zip Code: Supervisor's Name: Description of Duties: 23. Briefly summarize your aviation activities and professional responsibilities that best qualify you to be a designated pilot examiner.— ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ FAA Form 8710-12 (9-04) 4 American LegalNet, Inc. www.FormsWorkflow.com Form Approved OMB No. 2120-0690 24. During the past 5 years, were you fired from any job for any reason?— 25. Have you ever been convicted of any felony violation?—
YES
NO
YES 28. Have you ever been convicted by a military court-martial?— 26. Are you now under charges for any violation of law?—
NO
YES
NO 29. Have you ever been discharged from a military service under a General discharge?— 27. Have you ever been imprisoned, been on probation, or been on parole?—
YES
NO 30. Have you ever been discharged from a military service under other than honorable conditions?—
YES
NO
YES
NO
YES
NO 31. If you answered "YES" to any questions in Blocks 24 through 30, you MUST enter the full details. _________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ 32. Education and Training— Are you a high school graduate? Are you a GED graduate?

YES YES College and/or Technical Training Dates: From (mo/yr): To (mo/yr):

NO Name of High School:_______________________________Date Graduated (mo/yr):______________ NO Date received GED (mo/yr):__________________________ Name of School: Curriculum or Study Program: Degree or Certificate Received: RELEASE OF INFORMATION AND CERTIFICATION STATEMENT— — Read this statement CAREFULLY. After you read this statement, you MUST sign and date this application in black ink. Under your signature, you MUST print or type your name. • • • • • • • • 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 candidate, for not designating me, or terminating any designation I may receive. I understand that any information given may be investigated. I consent to the release of information regarding my personal and technical qualifications for designation as a pilot examiner 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 FAA has delegated the authority to screen and approve or disapprove pilot examiner applicants. I understand that, if my application is accepted, approval for assignment to the national examiner candidate pool is dependent on my passing the examiner predesignation knowledge test with a score of 80 percent or higher. I understand that assignment to the national examiner candidate pool does not guarantee selection or designation as a pilot examiner and that, if selected, designation is dependent on satisfactory completion of a practical test (demonstration of competency) and satisfactory completion of the Initial Sport Pilot Examiner Standardization Seminar. 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 pilot examiner is a privilege, not a right, and that any designation received may be terminated, revoked, or not renewed at any time 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 made in good faith. FAA Form 8710-12 (9-04) 5 American LegalNet, Inc. www.FormsWorkflow.com Form Approved OMB No. 2120-0690 33. Applicant's Signature —(Sign application in black ink.) —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 or representations, or entry, may be fined up to $250,000 or imprisoned not more than 5 years, or both. (18 U.S. Code Secs. 1001; 3571). Date signed—(Month, Day, Year) — (Print or type your name under your signature.) FAA Form 8710-12 (9-04) 6 American LegalNet, Inc. www.FormsWorkflow.com Form Approved OMB No. 2120-0690 FOR LIGHT-SPORT STANDARDIZATION BOARD USE ONLY (For Original Issuance Only)
Accepted for Predesignation Testing
Not Qualified Predesignation Test Score:____________________
Approved for Pool
Disapproved for Pool Date:_________________________ Date of Test:___________________ Date:___________________ Signature of LSSB Official:___________________________________________ Title:______________________________________ Referred to AFS-610
Selected
Date:___________________ D ate:___________________ Declined Inspector's Recommendation:
Approve
Disapprove Reason for Disapproval (Attach additional sheets, if required.): The individual submitting this application has satisfactorily demonstrated competency to perform the duties of the following designation(s):
SPE
SPFI Aircraft Categories:
Airplane
Powered Parachute
Weight-Shift Control Additional Qualifications/Limitations (if any):
Gyroplane
Glider
Airship
Balloon Inspector's Signature:_________________________________________________ Date: ________________________ AFS-610 Office:
Approve
Disapprove Date: _____________________ Signature: ____________________________________________________________________ Routing Symbol: _____________________ Date Certificate of Authority Issued: ___________________________ Examiner Number: _______________________________________________ Expiration Date: ______________________ Additional Regions to be served by the examiner (if any): FAA 8710-12 (9-04) 7 American LegalNet, Inc. www.FormsWorkflow.com