Free Statement of Qualifications (DAR, ODAR, DMIR, DER) - Federal

INFORMATION FOR APPLICANT
U.S. Department of Transportation

Federal Aviation Administration

STATEMENT OF QUALIFICATIONS (DAR--ODAR--DMIR--DER)

Privacy Act Statement
Information on this form is solicited under authority of 14 CFR Part 183. The purpose of this information is to evaluate your application and establish your qualifications as a designee. Submission of the data is mandatory except for your Social Security Number which is voluntary. Incomplete submission may result in delay or denial of your request. The data will be used to determine your eligibility for the designation sought, and will become part of the Privacy Act system of records DOT/FAA 830, Representatives of the Administrator, and is subject to the following routine uses as published in the Federal Register: (1) To provide the public with the names and addresses of certain categories of representatives who may provide service to them; and (2) DOT's Prefatory Statement of General Routine Uses. The submission of your social security number is voluntary. If provided, it will be used for record keeping purposes and to help prevent your records from being confused with another person of the same name.

Paperwork Reduction Act Statement: This collection of information is for the purpose of obtaining essential information concerning the applicants' professional and personal qualifications. The FAA uses the information provided to screen and select the designees who act as representatives of the Administrator in performing various certification and examination functions. The burden associated with new and renewal applications using FAA Form 8110-14 is between 30 minutes and 1 hour. Providing this information is mandatory if a person wishes to apply to become a Designated Representative. The information is protected under the provisions of the Privacy Act and the Privacy Act system of records DOT/ FAA-830, Representatives of the Administrator. 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 of information 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 this cover sheet before submitting this form.

FAA Form 8110-14 (6-00) Supersedes Previous Edition
N SN: 0052-00-047-2005

Organizations complete only the applicable blocks and attach separate resumes with the names, signatures, titles and qualifications of those persons who would actually perform the authorized functions.

U.S. Department of Transportation Federal Aviation Administration


STATEMENT OF QUALIFICATIONS (DAR--ODAR--DMIR--DER)

Form A pproved OMB No. 2120-0033 02/28/2007

3. U.S. CITIZEN Yes 4. SOCIAL SECURITY NO. 5. DATE OF BIRTH No

INSTRUCTIONS: Print or type all entries except signatures
1. NAME (Last, first, middle) OR ORGANIZATION 2. BUSINESS OR COMPANY ADDRESS (Number, street, city, state, and ZIP code)

6. BUSINESS PHONE NUMBER 9. DESIGNATION SOUGHT Designated Engineering
Representative (DER)
Company Consultant Manufacturing:

7. BUSINESS FAX NUMBER

8. EMAIL ADDRESS

Structural Engineering Powerplant Engineering Systems and Equipment Engineering Acoustical Engineering NOTE:

Engine Engineering Propeller Engineering Flight Analyst Flight Test Pilot

Designated Airworthiness Representative (DAR) Organizational Designated Airworthiness Representative (ODAR) Designated Manufacturing Inspection Representative (DMIR) Applicants shall identify specific function(s) for which appointment is sought:

A separate application must be submitted for each discipline, i.e., Manufacturing or Engineering.

10. EXPERIENCE RESUME FOR NUMBER OF YEARS, AS APPROPRIATE, PERTINENT TO DESIGNATION SOUGHT.
necessary)

(Use additional sheets if

Dates From To Employer's Name Position Title and Duties

11. EDUCATION AND TRAINING HIGH SCHOOL LEVEL AND ABOVE PERTINENT TO DESIGNATION SOUGHT. Dates From To Name of School Curriculum or Study Program Degrees Received

12. FAA CERTIFICATES NOW HELD PERTINENT TO DESIGNATION SOUGHT. Type Certificate No. Rating Date Each Rating Issued

13. EMPLOYER'S RECOMMENDATION: I recommend the person identified above be appointed as: Designated Engineering Representative Date Designated Manufacturing Inspection Representative Primary Business Organizational Designated Airworthiness Representative Signature

14. LOCATION WHERE DESIGNEE FUNCTIONS WILL BE PERFORMED IF DIFFERENT THAN BLOCK 2. Address Telephone Number

EMAIL Address (Optional)

15. CERTIFICATION: I certify that the above statements are true to the best of my knowledge and that I am familiar with the Federal Aviation Regulations pertinent to the designation sought. Date FAA Form 8110-14 (6-00) Supersedes Previous Edition Signature
N SN: 0052-00-047-2005