TEAR OFF BEFORE USE U.S. DEPARTMENT OF TRANSPORTATION FEDERAL AVIATION ADMINISTRATION SUPPLEMENTAL INFORMATION MECHANIC'S APPLICATION FOR INSPECTION AUTHORIZATION--PRIVACY ACT Information on FAA form 8610-1, Mechanic's Application for Inspection Authorization is solicited under the authority of 49 U.S.C. 44103 as implemented by 14 CFR Part 65. The purpose of this information is for the issuance and renewal of inspection authorizations. The information will become part of the Privacy Act system of records DOT/FAA 847, Aviation Records on Individuals, and the routine uses of that system will apply. Submission of this The information will only be used by the program office. Authorization or renewal cannot be issued without this information. Paperwork Reduction Act Statement: The information collected on this form is necessary to ensure applicant eligibility. The information is used to determine that the applicant meets the necessary qualifications for an original or renewal Mechanic's Inspection Authorization. We estimate that it will take approximately 20 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, Aviation 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 2120-0022. 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. FAA Form 8610-1 (2-78) SUPERSEDES PREVIOUS EDITION Detach this part before using form below American LegalNet, Inc. www.FormsWorkflow.com No certificate may be issued unless a completed application form has been received (14 C.F.R. 65) U.S. DEPARTMENT OF TRANSPORTATION Form Approved: OMB No. 2120-0022 11/30/07 2. MECHANIC CERTIFICATE NO. FEDERAL AVIATION ADMINISTRATION MECHANIC'S APPLICATION FOR INSPECTION AUTHORIZATION—PRIVACY ACT 1.NAME (Last, first, middle) 3.MAILING ADDRESS (Number, street, city, State/County, ZIP Code) (Place at which you desire to receive Airworthiness Directives, etc.) 4a. FIXED BASE OF OPERATIONS PLACE AT WHICH YOU MAY BE LOCATED IN PERSON DURING NORMAL WORKING WEEK 4b. TELEPHONE NO. PLACE AT WHICH YOU MAY BE LOCATED BY TELEPHONE DURING NORMAL WORKING WEEK 5. HAVE YOU HELD A MECHANIC CERTIFICATE WITH BOTH AIRFRAME AND POWERPLANT RATINGS FOR THE 3 YEARS PRECEDING THE DATE OF THIS APPLICATION? YES NO 6. HAVE YOU BEEN ACTIVELY ENGAGED, FOR AT LEAST THE 2-YEAR PERIOD BEFORE THE DATE OF APPLICATION IN MAINTAINING AIRCRAFT CERTIFICATED AND MAINTAINED IN ACCORDANCE WITH THE FARS? 7. HAS YOUR MECHANIC CERTIFICATE AND/OR RATINGS BEEN REVOKED OR SUSPENDED DURING THE 3—YEAR PERIOD PRECEDING THIS APPLICATION? 8. HAS AN INSPECTION AUTHORIZATION BEEN DENIED YOU WITHIN 90 DAYS PREVIOUS TO THIS APPLICATION? IF ANSWER IS "YES", EXPLAIN IN REMARKS. 9. HAVE YOU MET THE MINIMUM REQUIREMENTS FOR RENEWAL OF INSPECTION AUTHORIZATION? (For Renewal Only) ALTERATIONS 10. BASIS FOR RENEWAL (Number Performed) ANNUAL INSPECTIONS PROGRESSIVE INSPEC- RECENT ISSUANCE-IN EFFECT TIONS LESS THAN 90 DAYS BEFORE EXPIRATION DATE REPAIRS 11. AIRCRAFT MAINTENANCE ACTIVITY DURING LAST 2 YEARS NAME AND ADDRESS OF REPAIR STATION, FACILITY, MANUFACTURER, OPERATOR, ETC. DATES DESCRIPTION OF ACTIVITY FROM TO PRESENT FROM TO FROM TO FROM TO 12. REMARKS 13. CERTIFICATION: I certify that the statements made above and in all attachments hereto are correct and true. DATE SIGNATURE OF APPLICANT ISSUANCE VOLUNTARY SURRENDER ENDORSEMENT FAA Form 8610-1 (2-78) 14. RECORD OF ACTION (For FAA use only) INSPECTOR'S SIGNATURE OFFICE IDENTIFICATION RENEWAL SUPERSEDES PREVIOUS EDITION American LegalNet, Inc. www.FormsWorkflow.com