INFORMATION FOR APPLICANT U.S. Department of Transportation Federal Aviation Administration MEDICAL EXEMPTION PETITION (Operational Questionnaire) Privacy Act Statement Information requested on this form is solicited under the authority of Title 49 of the United States Code 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 of 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: Applicants not meeting the medical standards prescribed by Part 67, but who desire to perform aviation activities, must submit FAA Form 8500-20, Medical Exemption Petition (Operational Questionnaire), as part of the special issuance request. information obtained on this form facilitates a fair and equitable ruling that may permit applicants to perform operational activities that are commensurate with their medical condition and public safety. Submission of information is mandatory. The purpose of this information is to determine whether an applicant meets FAA medical requirements to hold an airman medical certificate for further consideration under Title 14 of the Code of Federal Regulations (CFR) 11.53 and 67.401. Any person who is denied a medical certificate by an aviation medical examiner may appeal to the Federal Air Surgeon under 14 CFR 67.409, Denial of medical certificate. This information is also used to depict airman population patterns and to update certification procedures and medical standards. If you wish to comment on the accuracy of the estimate or make suggestions for reducing this burden, please direct your comments to the FAA at the following address: Federal Aviation Administration; Aeromedical Certification Division, AAM-300; P.O. Box 26080; Oklahoma City, OK 73126-9922. The public reporting burden for collection of information is estimated to average 8 minutes per response The 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 paperwork burden associated with this form is currently approved under OMB number 2120-0034. 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 ORM 8500-20 (9-97) Supersedes Previous Edition American LegalNet, Inc. www.FormsWorkflow.com Form Approved OMB No. 2120-0034 01/31/2008 MEDICAL EXEMPTION PETITION (Operational Questionnaire) Name: (Last, First, Middle) Pl# Address: (No. Street, City, State, ZIP Code) Date of Birth: (Month, Day, Year) Check applicable item(s) in each category indicating how you plan to use the medical certificate for which you are applying. If additional space is needed for explanation, use reverse side of this form. 1. TYPES OF AIRCRAFT Single Engine Multi-engine Helicopter Jet Sea or Skiplane Experimental Special aircraft or equipment. Give details: Other: Give details. 2. TYPES OF OPERATIONS Acrobatics Daylight Operations Mountainous ( Aerial Application (cropdusting, etc.) Night Operations Remote (pipeline patrol, ranching) Aerial Patrol (police, fire, border, etc.) Instrument Flying Self-employed, Private feet elevation) Air Taxi Operations Supersonic Flight Flying involving carrying passengers for compensation or hire Altitudes above 8,000 feet Travel Club Flying involving carrying cargo for compensation or hire Corporate or Business Transoceanic, Over Water High Density Traffic, Metropolitan Areas Other: Give details. 3. DUTIES Pilot-in-Command Second-in-Command Flight Engineer Proficiency Instructor, Flight Training Check Pilot: Line Other: Give details. 4A. Maximum Daily Flight Time: (Circle AM or PM) 4B. Maximum Daily Duty Time: (Circle AM or PM) A.M. From: P. M. 4C. Scheduling Irregular: A. M. From: P.M. To: A.M. P.M. No Yes 5. Will you be under any medical supervision in your flight operations other that provided by FAA regulations? If YES, explain. No Yes 6. In carrying out your flight activities, will there be another qualified pilot In the cockpit on all flights? If YES, explain. No Yes 7. In the event you are found not qualified for the class of medical certificate sought, would you accept a lower class? If YES, explaln. No Yes To: A.M. P.M. FAA FORM 8500-20 (9-97) Supersedes Previous Edition American LegalNet, Inc. www.FormsWorkflow.com