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Examiner Designation And Qualification Record FAA 8710-6 - Official Federal Forms
| Examiner Designation And Qualification Record Form. This is a national form and can be used in Federal Aviation Administration (FAA) . |
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US Department of Transportation Federal Aviation Administration EXAMINER DESIGNATION AND QUALIFICATION RECORD Privacy Act Statement: The information on this form is solicited under authority of the Federal Aviation Regulations Part 183. The purpose of this information is to establish your qualifications as an examiner. Submission of the data is mandatory. Incomplete submission may result in delay or denial of y our request. The data will be used to determine your eligibility as an examiner, and for statistical purposes. In addition, the data also becomes part of the Privacy Act system of records DOT/FAA 830, Representatives of the Administrator, and is subject to the additional conditions of that published system. Paperwork Reduction Act Statement: The information collected on this form is necessary to determine applicant eligibility for Designated Pilot Examiner, Proficiency Pilot Examiner, and Airman Certification Representative. The information is used to determine certification eligibility. We estimate that it will take 30 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 830, Representatives of the Administrator. 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 2120-0033. 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. TEAR OFF BEFORE USE FAA Form 8710-6 (10-83) SUPPLEMENTAL INFORMATION Detach this part before using form below. American LegalNet, Inc. www.FormsWorkflow.com Form Approved OMB No. 2120-0033 11/30/2007 TYPE OF DESIGNATION PRIVATE PILOT COMMERCIAL PILOT EXAMINER AIRLINE TRANSPORT PILOT EXAMINER PROFICIENCY PILOT EXAMINER FLIGHT ENGINEER EXAMINER FLIGHT INSTRUCTOR EXAMINER OTHER YES NO 5. DO YOU NOW HOLD, OR HAVE YOU EVER HELD, AN EXAMINER DESIGNATION YES NO TYPE AND NUMBER US Department of Transportation Federal Aviation Administration EXAMINER DESIGNATION AND QUALIFICATION RECORD Attach supplemental sheets if more space is required for any item. 1. NAME (Last, first, middle) 2. ADDRESS (Number, street, city, state, and ZIP code) Telephone No. 3. DATE OF BIRTH (Month, day, and year) 4. U.S. CITIZEN 6. HAS ANY CERTIFICATE OR RATING ISSUED YOU EVER BEEN SUSPENDED OR REVOKED OR HAVE YOU PAID A CIVIL PENALTY AS A RESULT OF A VIOLATION OF THE FEDERAL AVIATION REGULATIONS. (Complete for original designations only.) YES NO 7. CERTIFICATES HELD TYPE CERTIFICATE NO. RATINGS DATE ISSUED 8. FLIGHT EXPERIENCE (in hours) AIRPLANE TOTAL LAST 12 MOS. ROTORCRAFT TOTAL LAST 12 MOS. TOTAL GLIDERS LAST 12 MOS. INSTRUMENT FLIGHT (Actual or sim) NIGHT FLIGHT PILOT-IN-COMMAND FLIGHT INSTRUCTION GIVEN COPILOT FLIGHT NAVIGATOR FLIGHT ENGINEER 9. EMPLOYMENT (Indicate professional experience pertinent to this designation) EMPLOYER'S NAME NATURE OF WORK DATES TITLE OF POSITION 10. SPECIAL TRAINING PERTINENT TO THE DESIGNATION CERTIFICATION: I certify that I am familiar with the requirements for this designation, its privileges and limitations, and that the information stated herein is true. It is understood that this designation may be terminated upon notice by the FAA for the reasons specified in section 183.15(c) of the Federal Aviation Regulations. DATE SIGNATURE FAA Form 8710-6 (10-83) American LegalNet, Inc. www.FormsWorkflow.com FOR FAA USE TYPE OF ACTION ORIGINAL ISSUANCE RENEWAL ADDITIONAL AUTHORITY SPOT CHECK ONLY NO RENEWAL EFFECTED REINSTATEMENT FLIGHT TEST ACTIVITIES-GENERAL AVIATION (Complete for renewals and additional designations) CERTIFICATES/RATINGS PRIVATE PILOT COMMERCIAL PILOT AIRLINE TRANSPORT PILOT INSTRUMENT RATING ADDITIONAL RATINGS PRIVATE COMMERCIAL ATR TOTAL DISAPPROVED SUBMITTED BY EXAMINER ACCEPTED BY INSPECTOR DATE LAST REPORT SUBMITTED RECHECKED BY INSPECTOR NO. RETURNED FOR CORRECTION CHARACTER AND REPUTATION (Include industry and community reputation as well as personal knowledge possessed by FAA personnel) Complete for original issuance and reinstatements only PROFESSIONAL ABILITY (Brief narrative description of examiner indoctrination and training given and results expressed as "good," "excellent," or "unsatisfactory.") INSPECTOR'S RECOMMENDATION/ACTION JUSTIFICATION FOR APPROVAL/REASONS FOR DISAPPROVAL APPROVE DISAPPROVE The individual named has been flight tested/examined and deemed competent to perform the duties of the designation indicated below. PRIVATE PILOT DESIGNATION COMMERCIAL PILOT EXAMINER AIRLINE TRANSPORT PILOT EXAMINER PROFICIENCY PILOT EXAMINER FLIGHT ENGINEER EXAMINER FLIGHT INSTRUCTOR EXAMINER OTHER DATE CATEGORY AIRPLANE ROTOCRAFT GLIDER OFFICE NO. INSPECTOR'S SIGNATURE ADDITIONAL QUALIFICATIONS LIMITATIONS (For pilot flight engineer examiner give aircraft category) REGIONAL OFFICE ACTION CONCUR DISAPPROVE TYPE OF DESIGNATION NO. CERTIFICATE OF AUTHORITY ISSUED DO TO SERVE UNDER EXPIRATION DATE DATE SIGNATURE American LegalNet, Inc. www.FormsWorkflow.com
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