Free ATA54972-A.PDF - Federal

APPLICATION FOR EMPLOYMENT WITH THE FEDERAL AVIATION ADMINISTRATION

INSTRUCTIONS

READ AND FOLLOW THESE INSTRUCTIONS CAREFULLY. IF YOUR FORM IS NOT COMPLETED CORRECTLY, WE WILL BE UNABLE TO PROCESS YOUR APPLICATION AND UNABLE TO CONSIDER YOU FOR EMPLOYMENT. · You must enter your Social Security Number (SSN) on the bottom of each page of this form. This assures that the pages are processed together. Executive Order 9397 authorized the solicitation of your SSN for use as an identifier in personnel records management, thus assuring proper identification of applicants throughout the selection and employment process. The information we collect by using your SSN will be used for employment purposes and may also be used for studies, statistics, and computer matching to benefit or payment files. Furnishing your SSN or any of the other information specified in the vacancy announcement is voluntary. However, failure to do so will prevent the processing of your application and will prevent consideration for employment. DO NOT submit a resume or Application for Federal Employment (SF-171 or OF-612) in lieu of completing this application form. You must certify the application form by reading, answering, signing, and dating the "SIGNATURE, CERTIFICATION, AND RELEASE OF INFORMATION" questions, or your application form will not be processed. For statistical purposes, please complete the "RACE AND NATIONAL ORIGIN IDENTIFICATION" form (the last page of this form). This information is voluntary. Failure to provide it will not affect your consideration for employment. It does assure that our employment practices are free from prohibited discrimination and provide equal employment opportunities for all.

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· Please make and retain a copy of FAA Form 54972 for your records. · Please remove this instruction sheet before submitting your application.
Mail your completed application form to:

Aviation Careers Division AMH300 FAA MM Aeronautical Center P.O. Box 26650 Oklahoma City, OK 73126-0650

FAA Form 54972 Cover Sheet 02/01

AIR TRAFFIC ASSISTANT AT-2154-07 (Flight Data Communications Specialist) U.S. DEPARTMENT OF TRANSPORTATION FEDERAL AVIATION ADMINISTRATION APPLICATION FOR EMPLOYMENT WITH THE FEDERAL AVIATION ADMINISTRATION FAA-AAT-01-ATA01-54972
SSN _________-________-________ Day Phone (_____) _____-________ Name ________________________________________________________
Last Street First MI

Address _______________________________________________________ ______________________________
City

Night Phone (_____) _____-________ Date of Birth ______/______/_______

______
Ste Country

________-______
Zip

Place of ______________________ Birth City

_______
Ste

______________________

SIGNATURE, CERTIFICATION, AND RELEASE OF INFORMATION YOU MUST COMPLETE THIS PORTION OF THE FORM IN ORDER TO BE CONSIDERED FOR FEDERAL AVIATION ADMINISTRATION EMPLOYMENT NOTE: You must sign the application and answer each question below. If these four questions are not answered "YES," your application cannot be considered. Read the following carefully before you sign this form:
· I understand that a false statement on any part of this application may be grounds for not hiring me or for firing me after I begin work. I also understand that I may be punished by fine or imprisoned for falsification of my employment application (18 USC 1001)._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 0 Yes I understand that information I give may be investigated as allowed by law or Presidential order. _ _ _ _ _ _ _ _ _ 0 Yes 0 No 0 No

· ·

I consent to the release of information concerning my background, ability, and fitness for employment with the Federal Aviation Administration by employers, schools, law enforcement agencies, other individuals and organizations to investigators, personnel staffing specialists, and other authorized employees of the Federal Aviation Administration. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 0 Yes I certify that, to the best of my knowledge and belief, ALL of the information provided on this application is true, accurate, and complete, and that this application for employment with the Federal Aviation Administration is made in good faith. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 0 Yes

0 No

·

0 No

_________________________________________________
(Signature) Privacy Act and Public Burden Statements

___________________________
(Month) (Day) (Year)

Public Law 104-50 allows the Federal Aviation Administration (FAA) to rate applicants for employment. We need the information on this application questionnaire to see how well your education and work skills qualify you for employment with the FAA. We also need information on matters such as citizenship and military service to see whether you are affected by laws we must follow in deciding whom the Federal government may employ. Executive Order 9397 authorizes the solicitation of your Social Security Number (SSN) for use as an identifier in personnel records management to assure proper identification of applicants throughout the selection and employment process. The information we collect on this questionnaire, including your SSN, will be used for employment purposes, and it may also be used for statistical studies or computer matching with other government files. Furnishing your SSN or any of the other information requested in the vacancy announcement is voluntary; however, failure to provide this information will prevent the processing of your application and will prevent your consideration for employment. The nature of the information received is confidential, and authorized officials will handle it appropriately. This information becomes part of a Privacy Act System of Records as identified in 5CFR 552a, under OPM/GOVT-1: General Personnel Records. We estimate it will take you 60 minutes to complete this form, including the time required to read the instructions, provide the requested information, and review your responses. Send comments regarding this estimate or any other aspect of the collection of information, including suggestions for reducing the burden, to the Federal Aviation Administration, Office of Human Resource Management, 800 Independence Avenue, SW, Washington D.C. 20591.

FAA Form 54972 (02/01)

1

Read each question carefully. Darken the circle for the ONE answer that best describes you. Multiple or blank responses will result in that question receiving the least credit. Section 1: APPLICANT INFORMATION 1. I am a citizen of the United States, Guam, American Samoa, U.S. Virgin Islands, or Puerto Rico. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 2. I am registered with the Selective Service System, or I have a valid exemption from registration. (NOTE: If you are a female, or were born before December 31, 1959, answer YES to this question.) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 0 Yes 0 No

0 Yes

0 No 0 No 0 No 0 No 0 No 0 No 0 No

3. I have advocated or knowingly associated with a group advocating the overthrow of the United States Government or I have participated in a strike against the United States Government. _ 0 Yes 4. I am currently a permanent civilian employee of the Federal Aviation Administration. _ _ _ _ _ 5. I am currently a permanent civilian employee or I have been a permanent civilian employee of a Federal agency. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 6. I am currently a temporary civilian employee of a Federal agency. _ _ _ _ _ _ _ _ _ _ _ _ _ _ 7. I am able to communicate orally and in writing in the English language. _ _ _ _ _ _ _ _ _ _ _ _ 8. I am able to communicate orally and in writing in a language other than English. _ _ _ _ _ _ _ Section 2: MILITARY SERVICE 0 Yes 0 Yes 0 Yes 0 Yes 0 Yes

To claim veterans' preference you are required to submit a copy of your DD-214, Armed Forces of the United States Report of Transfer or Discharge and if applicable, a SF-15, Application for 10-Point Veteran Preference, along with required proof. 1. I have served on active duty in the United States military service. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 2. I am claiming 5-point veteran preference based on my active duty military service. NOTE: Must submit a copy of your DD-214. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 3. I am claiming 10-point veteran preference as the spouse, widow, widower or natural mother of a disabled or deceased veteran. NOTE: Must submit SF-15 with required proof. _ _ _ _ _ _ 4. I am claiming 10-point veteran preference as a Purple Heart recipient or have a serviceconnected disability of less than 10%. NOTE: Must submit SF-15 with required proof. _ _ _ 5. I am claiming 10-point veteran preference based on a service-connected disability rated at 10% or more, but less than 30%. NOTE: Must submit SF-15 with required proof. _ _ _ _ _ 6. I am claiming 10-point veteran preference based on a service-connected disability rated at 30% or more. NOTE: Must submit SF-15 with required proof. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 7. I retired or will be retiring from military service at or above the rank of major (0-4) or its equivalent. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ SSN: _______-______-__________ FAA Form 54972 (02/01) 0 Yes 0 Yes 0 Yes 0 Yes 0 Yes 0 Yes 0 Yes 0 No 0 No 0 No 0 No 0 No 0 No 0 No 2

Section 3: FACILITY PREFERENCES Select up to three (3) facilities where you wish to be employed. If you are willing to work at any of the facilities, select All Facilities. You will only be referred for employment consideration to these facilities and you will only be referred to one facility at a time. All selections are of equal preference. If you select more than three (3) facilities, only the first three (3) will be considered.

ALASKAN REGION 0 Anchorage ARTCC, Anchorage, AK CENTRAL REGION 0 Kansas City ARTCC, Olathe, KS EASTERN REGION 0 Washington ARTCC, Leesburg, VA 0 New York ARTCC, Ronkonkoma, NY GREAT LAKES REGION 0 Chicago ARTCC, Aurora, IL 0 Minneapolis ARTCC, Farmington, MN 0 Cleveland ARTCC, Oberlin, OH 0 Indianapolis ARTCC, Indianapolis, IN NEW ENGLAND REGION 0 Boston ARTCC, Nashua, NH NORTHWEST MOUNTAIN REGION 0 Denver ARTCC, Longmont, CO 0 Seattle ARTCC, Auburn, WA 0 Salt Lake City ARTCC, Salt Lake City, UT SOUTHERN REGION 0 Jacksonville ARTCC, Hilliard, FL 0 Miami ARTCC, Miami, FL 0 Atlanta ARTCC, Hampton, GA 0 Memphis ARTCC, Memphis, TN SOUTHWEST REGION 0 Albuquerque ARTCC, Albuquerque, NM 0 Fort Worth ARTCC, Fort Worth, TX 0 Houston ARTCC, Houston, TX WESTERN-PACIFIC REGION 0 Los Angeles ARTCC, Palmdale, CA 0 Oakland ARTCC, Fremont, CA 0 ALL FACILITIES

SSN: _______-______-__________

FAA Form 54972 (02/01)

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Section 4: DIRECTLY RELATED WORK EXPERIENCE Please describe your paid and non-paid work experience related to the Air Traffic Assistant position. Please list only the 5 most relevant jobs. Do not attach job descriptions. _______________________________________________________________________________________
A. Job Title (if Federal, include series and grade)

From (mm/yy)

To (mm/yy)

Salary $

per

Hours per week Supervisor's name and phone number ( )

Employer's name and address

Describe your duties

_______________________________________________________________________________________
B. Job Title (if Federal, include series and grade)

From (mm/yy)

To (mm/yy)

Salary $

per

Hours per week Supervisor's name and phone number ( )

Employer's name and address

Describe your duties

SSN: _______-______-__________

FAA Form 54972 (02/01)

4

_______________________________________________________________________________________
C. Job Title (if Federal, include series and grade)

From (mm/yy)

To (mm/yy)

Salary $

per

Hours per week Supervisor's name and phone number ( )

Employer's name and address

Describe your duties

_______________________________________________________________________________________
D. Job Title (if Federal, include series and grade)

From (mm/yy)

To (mm/yy)

Salary $

per

Hours per week Supervisor's name and phone number ( )

Employer's name and address

Describe your duties

______________________________________________________________________________________
E. Job Title (if Federal, include series and grade)

From (mm/yy)

To (mm/yy)

Salary $

per

Hours per week Supervisor's name and phone number ( )

Employer's name and address

Describe your duties

SSN: _______-______-__________

FAA Form 54972 (02/01)

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Section 5: EDUCATION AND TRAINING Place an "X" in appropriate box and complete requested information. Education Some High School High School/GED Colleges and universities attended. Do not attach a copy of your transcript. Credits Earned Name and Address Major (sem or qtr)
1.

"X"

Name and Address

Year Diploma or GED Received

Degree

Year Received

2.

3.

Section 6: OTHER QUALIFICATIONS List any other job-related training courses (give title and year); job-related skills (other languages, computer hardware/software, machinery, typing speed etc.); job-related honors, awards and special accomplishments (publications, memberships in professional/honor societies, leadership activities, public speaking, and performance awards.) Give dates, but do not send documents.

SSN: _______-______-__________

FAA Form 54972 (02/01)

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Section 7: AVIATION WORK EXPERIENCE This section enables us to identify the types of aviation positions you have held which have prepared you to perform various aspects of the Flight Data Communications Specialist job. Enter an "X" if you have had either civilian or military aviation work experience. Also, indicate at which job listed on pages 4 and 5 of this form you obtained the experience. 1. TYPE OF JOB a. Flight Data Processor or Specialist b. Air Traffic Controller or Specialist c. Flight Data Aide d. Flight Data Communications Specialist e. Airfield Management Specialist f. Operations Specialist g. Aerospace and Warning Control Systems Operator h. Flight Dispatcher i. Air Transport Pilot j. Flight Engineer k. Flight Instructor l. Ground Instructor m. Navigator n. Pilot (Instrument Flight Rules) o. Pilot (Visual Flight Rules) p. Flight Information Expediter q. Airline Flight Planning Services r. Computer/Data Entry Clerk s. Other (Specify) "X" A 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 A 0 0 0 0 0 0 0 0 0 0 0 A 0 0 0 0 0 B 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 B 0 0 0 0 0 0 0 0 0 0 0 B 0 0 0 0 0 C 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 C 0 0 0 0 0 0 0 0 0 0 0 C 0 0 0 0 0 D 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 D 0 0 0 0 0 0 0 0 0 0 0 D 0 0 0 0 0 E 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 E 0 0 0 0 0 0 0 0 0 0 0 E 0 0 0 0 0

2. WORK SETTING a. Federal Aviation Administration b. Air Traffic Control Contractor c. Military (Air Force, Army, etc.) d. Airline e. Air Cargo Service f. Air Taxi Service g. Flight School h. Aircraft Ferry Service i. Weather Service j. Police or Fire Department k. Other (Specify)

"X"

3. TYPE OF AIRCRAFT INVOLVED IN JOB a. Single Engine b. Multi Engine c. Jet d. Helicopter e. Other (Specify)

"X"

SSN: _______-______-__________

FAA Form 54972 (02/01)

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4. CERTIFICATES(S), RATINGS(S), OR LICENSE(S) REQUIRED TO PERFORM YOUR JOB a. Air Traffic Control Specialist b. Control Tower Operator with a Facility Rating c. Air Traffic Control Operations Examiner d. Flight Dispatcher e. Air Transport Pilot f. Instrument g. Instrument Helicopter h. Commercial Pilot i. Multi Engine j. Navigator k. Flight Engineer l. Flight Instructor m. Ground Instructor n. Private Pilot o. Other (Specify)

"X"

A 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

B 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

C 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

D 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

E 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

5. List below all aviation related ratings, certificates or licenses you have held. RATINGS, CERTIFICATES OR CERTIFICATE OR LICENSE LICENSES NUMBER a. b. c. d. e.

DATE RECEIVED

6. TIME SPENT IN JOB a. 1 to 5 months b. 6 to 11 months c. 12 months or more

"X"

A 0 0 0

B 0 0 0

C 0 0 0

D 0 0 0

E 0 0 0

NOTE: Convert part-time work to equivalent full time months. For example: Eight (8) months at twenty (20) hours per week equals four (4) months full-time. Full time is forty (40) hours per week.

SSN: _______-______-__________

FAA Form 54972 (02/01)

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Section 8: WORK ACTIVITIES Section 8 provides us with a detailed assessment of your qualifications for Flight Data Communications Specialist positions. Using the "Rating Scale," mark the level at which you performed each of the activities. Also indicate whether the activity was performed on the job, in coursework or during unpaid volunteer experience. Be sure related work experience, coursework and volunteer experience is reflected on pages 4, 5 and 6 of this form. RATING SCALE N/A - Not Applicable. I have not performed this activity. 1 - I performed this activity as a trainee. 2 - I performed this activity under supervision. 3 - I performed this activity independently. 4 - I trained or guided others in performing this activity. WORK ACTIVITIES PERFORMANCE LEVEL N/A 1 2 3 4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 JOB COURSE WORK VOLUNTEER

1. Enter flight plans or flight plan data into FAA or military Air Route Traffic Control computer. 2. Enter flight plans or flight plan data into a computer for an airline, air taxi or other private company. 3. Prepare and file instrument flight plans. 4. Relay flight plan data to or from Air Route Traffic Control centers, terminals, flight service stations, airline base operations, military bases or foreign towers using radio or telephone. 5. Identify and correct erroneous, duplicate and missing flight plan data such as, routes of flight, altitude and estimated times. 6. Write flight plans manually, including routes of Flight, estimate departure or arrival time, type of aircraft, etc. 7. Monitor Air Traffic Controller's transmissions to record flight plan changes or military scramble information. 8. Give IFR clearances to pilots by radio or telephone. 9. Give VFR clearances to pilots by radio or telephone. 10. Request and receive IFR clearances from Air Route Traffic Control centers, terminals or flight service stations. 11. Request and receive VFR clearances from Air Route Traffic Control centers, terminals or flight service stations. 12. Make flight decisions using knowledge of aircraft types and their speed and altitude characteristics. 13. Calculate flight time estimates. 14. Use airway maps to determine routes of flight. SSN: _______-______-__________

0 0 0 0

0 0 0 0

0 0 0 0

0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 9

FAA Form 54972 (02/01)

WORK ACTIVITIES - continued

PERFORMANCE LEVEL N/A 1 2 3 4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

JOB

COURSE WORK

VOLUNTEER

15. Transmit flight plan data to the military by the Aircraft Movement Identification System (AMIS). 16. Identify unknown aircraft crossing the Air Defense Identification Zone (ADIZ). 17. Interpret coded weather information transmitted by the Weather Bureau. 18. Identify information concerning weather and other conditions which are important to aircraft by examining weather reports, pilots reports, or Notices to Airmen (NOTAMS). 19. Compose weather reports or reports of other conditions affecting aircraft operations. 20. Read aloud weather or other information to make a tape recording of public service messages such as Automatic Terminal Information Service (ATIS) reports. 21. Perform counts of aircraft or other operations on a daily, weekly, or other basis. 22. Operate the air traffic simulation equipment. 23. Operate aircraft or helicopter simulator. 24. Operate teletypewriter. 25. Operate cryptographic typewriter. 26. Operate two-way radio. 27. Operate computer terminal (not air traffic control computer). 28. Operate typewriter, keypunch or other alphanumeric keyboard machine (not a computer terminal or teletypewriter). 29. Give on-the-job training to other employees. 30. Instruct groups of people in a formal classroom setting. 31. Determine proper routing of written, teletyped or computer-produced communications. 32. Deliver mail, messages or other materials. 33. Proofread typed or printed documents. 34. Correct or revise information on standard forms or records (not flight plan data). 35. Dispatch fire, police, ambulance or other emergency vehicles and personnel. 36. Answer questions, handle complaints, or take product or service orders from customers, the general public, etc. 37. Plan and organize activities that require an immediate and accurate decision. 38. Access, process and distribute classified material, up to and including secret. 39. Maintain communication and data files, records, publications, handbooks and directives.
SSN: _______-______-__________

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

FAA Form 54972 (02/01)

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RACE AND NATIONAL ORIGIN IDENTIFICATION
(Please read the instructions and Privacy Act Statement before completing form).

NAME: _________________________________________________________________________________
Last First MI

The categories below provide descriptions of race and national origins. Read the Definition of Category descriptions and then blacken the circle next to the category with which you identify yourself. If you are of mixed race and/or national origin, select the category with which you most closely identify yourself. Please mark only one circle. Name of Male Female Definition of Category Category 0 0 American Indian or Alaskan Native Asian or Pacific Islander A person having origins in any of the original peoples of North America, and who maintains cultural identification through community recognition or tribal affiliation. A person having origins in any of the original peoples of the Far East, Southeast Asia, the Indian subcontinent, or the Pacific Islands. For example, this area includes China, India, Japan, Korea, the Philippine Islands, and Samoa. A person having origins in any black racial groups of Africa. This does not include persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish cultures or origins. A person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish cultures or origins. This does not include persons of Portuguese culture or origin. A person having origins in any of the original peoples of Europe, North America, or the Middle East. This does not include persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish cultures or origins.
Privacy Act and Public Burden Statements Solicitation of this information is authorized by section 2000e-16 of title 42, which requires that agency employment practices be free from discrimination and provide equal employment opportunities for all, and by the Uniform Guidelines on Employee Selection Procedures (1978), 43 FR 38297 et seq. (August 25, 1978), which requires agencies to examine their employee selection procedures to identify any adverse impact those procedures have on women and minorities. Solicitation of this information is in accordance with Department of Commerce Directive 15, "Race and Ethnic Standards for Federal Statistics and Administrative Reporting." This information will be used to make statistical determinations under the Federal Equal Opportunity Recruitment Program (5 USC 7201) and affirmative action programs under section 717 of the title VII of the Civil Rights Act of 1964 as amended. The furnishing of this data is voluntary; however, collection of the information is essential to the design and maintenance of effective recruitment and preemployment processing programs which will provide the best possible employment opportunities to all candidates. You are requested to furnish your social security number (SSN) under the authority of Executive Order 9397 (November 22, 1943), which requires agencies to use the SSN for the sake of economy and orderly administration in the maintenance of personnel records. Furnishing of the SSN is voluntary; however, failure to provide the SSN may result in inaccurate statistical records. The public reporting burden for completing this form is estimated to vary from 1 to 3 minutes with an average of 2 minutes. The estimate includes time for reviewing instructions, gathering data needed, and completing and reviewing entries. Send comments regarding the burden estimate or any other aspect of this form, including suggestions for reducing the burden to: Federal Aviation Administration, Office of Human Resource Management, 800 Independence Avenue, SW, Washington D.C. 20591.

0

0

0

0

Black, not of Hispanic origin

0

0

Hispanic

0

0

White, not of Hispanic origin

SSN: _______-______-__________

FAA Form CAPS RNO (3/99)

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