| I. | APPLICATION INFORMATION.
Check appropriate blocks(s).
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| Block A. Name.
Enter legal name. Use no more than one middle name for
record purposes. Do not change the name on subsequent applications unless it
is done in accordance with 14 CFR Section 61.25. If you do not have a
middle name, enter "NMN". If you have a middle initial only, indicate
"Initial only." If you are a Jr., or a II, or III, so indicate. If you have an FAA
certificate, the name on the application should be the same as the name on the
certificate unless you have had it changed in accordance with 14 CFR Section
61.25.
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Block B. Social Security Number.
Optional: See supplemental
Information Privacy Act. Do not leave blank: Use only US Social Security
Number. Enter either "SSN" or the words "Do not Use" or "None." SSN's
are not shown on certificates.
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| Block C. Date of Birth.
Check for accuracy. Enter eight digits; Use
numeric characters, i.e., 07-09-1925 instead of July 9, 1925. Check to see that
DOB is the same as it is on the medical certificate.
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| Block D. Place of Birth.
If you were born in the USA, enter the city and
state where you were born. If the city is unknown, enter the county and state.
If you were born outside the USA, enter the name of the city and country
where you were born.
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| Block E. Permanent
Mailing Address. Enter residence number and street, P.O. Box or
rural route number in the top part of the block above the line. The City,
State, and ZIP code go in the bottom part of the block below the line.
Check for accuracy. Make sure the numbers are not transposed. FAA policy
requires that you use your permanent mailing address. Justification must
be provided on a separate sheet of paper signed and submitted with the
application when a PO Box or rural route number is used in place of your
permanent physical address. A map or directions must be provided if a
physical address is unavailable.
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| Block F. Citizenship.
Check USA if applicable. If not, enter the country
where you are a citizen.
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| Block G. Do you read, speak, write and
understand the English language?
Check yes or no.
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| Block H. Height.
Enter your height in inches. Example: 5'8" would be
entered as 68 in. No fractions, use whole inches only.
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| Block I. Weight.
Enter your weight in pounds. No fractions, use whole
pounds only.
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| Block J. Hair.
Spell out the color of your hair. If bald, enter "Bald."
Color should be listed as black, red, brown, blond, or gray. If you wear a wig
or toupee, enter the color of your hair under the wig or toupee.
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| Block K. Eyes.
Spell out the color of your eyes. The color should be listed
as blue, brown, black, hazel, green, or gray.
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| Block L. Sex.
Check male or female.
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| Block M. Do You Now Hold or Have You Ever
Held An FAA Pilot Certificate?
Check yes or no. (NOTE: A student pilot certificate is a
"Pilot Certificate.")
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| Block N. Grade of Pilot Certificate.
Enter the grade of pilot certificate
(i.e., Student, Recreational, Private, Commercial, or ATP). Do NOT enter
flight instructor certificate information.
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| Block O. Certificate Number.
Enter the number as it appears on your
pilot certificate.
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| Block P. Date Issued.
Enter the date your pilot certificate was issued.
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| Block Q. Do You Now Hold A Medical
Certificate?
Check yes or
no. If yes, complete Blocks R, S, and T.
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| Block R. Class of Certificate.
Enter the class as shown on the medical
certificate, i.e., 1st, 2nd, or 3rd class.
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| Block S. Date Issued.
Enter the date your medical certificate was issued.
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| Block T. Name of Examiner.
Enter the name as shown on medical
certificate.
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| Block U. Narcotics, Drugs.
Check appropriate block. Only check "Yes"
if you have actually been convicted. If you have been charged with a
violation which has not been adjudicated, check ."No".
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| Block V. Date of Final Conviction.
If block "U" was checked "Yes"
give the date of final conviction.
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| II. | CERTIFICATE OR RATING APPLIED FOR ON BASIS
OF:
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| Block A. Completion of Required Test.
1. AIRCRAFT TO BE USED. (If flight test required) – Enter the make and
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model of each aircraft used. If simulator or FTD, indicate.
2. TOTAL TIME IN THIS AIRCRAFT (Hrs.) – (a) Enter the total Flight
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Time in each make and model. (b) Pilot-In-Command Flight Time - In
each make and model.
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| Block B. Military Competence Obtained
In.
Enter your branch of
service, date rated as a military pilot, your rank, or grade and service number.
In block 4a or 4b, enter the make and model of each military aircraft used to
qualify (as appropriate).
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| Block C. Graduate of Approved Course.
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1. NAME AND LOCATION OF TRAINING AGENCY/CENTER.
As shown on the graduation certificate. Be sure the location is entered.
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2. AGENCY SCHOOL/CENTER CERTIFICATION NUMBER. As shown
on the graduation certificate. Indicate if 142 training center.
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3. CURRICULUM FROM WHICH GRADUATED. As shown on the
graduation certificate.
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4. DATE. Date of graduation from indicated course. Approved course
graduate must also complete Block "A" COMPLETION OF REQUIRED
TEST.
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| Block D. Holder of Foreign License Issued
By.
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1. COUNTRY. Country which issued the license.
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2. GRADE OF LICENSE. Grade of license issued, i.e., private, commercial,
etc.
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3. NUMBER. Number which appears on the license.
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4. RATINGS. All ratings that appear on the license.
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| Block E. Completion of Air Carrier's
Approved Training Program.
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1. Name of Air Carrier.
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2. Date program was completed.
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3. Identify the Training Curriculum.
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| III. | RECORD OF PILOT TIME.
The minimum pilot experience required
by the appropriate regulation must be entered. It is recommended, however,
that ALL pilot time be entered. If decimal points are used, be sure they are
legible. Night flying must be entered when required. You should fill in the
blocks that apply and ignore the blocks that do not. Second In Command
"SIC" time used may be entered in the appropriate blocks. Flight Simulator,
Flight Training Device and PCATD time may be entered in the boxes
provided. Total, Instruction received, and Instrument Time should be entered
in the top, middle, or bottom of the boxes provided as appropriate.
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| IV. |
HAVE YOU FAILED A TEST FOR THIS
CERTIFICATE OR RATING?
Check appropriate block.
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| V. | APPLICANT'S CERTIFICATION.
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A. SIGNATURE. The way you normally sign your name.
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B. DATE. The date you sign the application.
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