Free 3330473.DOC - Federal

FORM APPROVED OMB NO. 2120-0500

Supplemental Qualifications Statement U.S. Department of Transportation Federal Aviation Administration
1. Name (First, MI, Last) 2. Date of Birth (Mo/Da/Yr) 3. Social Security Number Type Airline Transport Pilot Commercial Pilot Private Pilot Flight Instructor

FOR 1825 AND 2181 SERIES
4. AIRMAN CERTIFICATES HELD
Date Issued Certificate No.

5. PILOT RATING RECORD Indicate certificate privileges for the ratings listed below by writing "A" for Airline Transport, "C" for Commercial or "P" for Private in column 1. Write an "F" for Flight Instructor Rating in column 2, where appropriate 1 2 1 2 Type Ratings: (specify) Airplane Single Engine Land Glider Airplane Single Engine Sea Rotorcraft Helicopter Airplane Multiengine Land Rotorcraft Gyroplane Airplane Multiengine Sea Lighter-than-air Free Instrument Airplane Balloon Instrument Helicopter Lighter-than-air Airship

6. TEST PILOT EXPERIENCE
Name of Company or Organization Flight Test Pilot Production Test Pilot Name of Company or Organization Date Employed Hours Hours Date Employed Fixed Wing Hours RotoCraft Hours

7. FAA DESIGNATIONS AND AUTHORIZATIONS
Date Issued Designated Pilot Examiner Pilot Proficiency Examiner Designated Flight Engineer Examiner Designated Aircraft Dispatcher Examiner Check Airman Aircrew Program Designee Designated Airworthiness Representative Designated Manufacturing Inspection Representative Designated Engineering Representative Designated Parachute Rigger Examiner

8. TYPE AND TOTAL FLIGHT HOURS
Total Pilot Time Single Engine Twin Engine Three or more Engine Multiengine over 12,500 lbs maximum Certificated Takeoff Weight Turbine Powered Turbo Powered Actual Instrument Hood Instrument Flight Simulator Night Total Flight Instructor Instrument Instructor Multiengine Instructor Total in Last 12 Months Total in Last 3 Years Total in Last 5 Years

Total Hours Flown to Date Airplane PIC SIC Rotorcraft PIC SIC

9. AIRCRAFT
Make/Model/Series Total Hours Flown to Date Flt Engr PIC SIC

FAA Form 3330-47-3 (10/98)