Form Approved OMB NO. 2120-0033 04/30/2010
PRIVATE PILOT
EXAMINER DESIGNATION
U.S. Department of Transportation Federal Aviation Administration 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.
TYPE OF DESIGNATION
COMMERCIAL PILOT EXAMINER AIRLINE TRANSPORT PILOT EXAMINER PROFICIENCY PILOT EXAMINER FLIGHT ENGINEER EXAMINER FLIGHT INSTRUCTOR EXAMINER OTHER 4. U.S. CITIZEN YES NO
AND QUALIFICATION RECORD
3. DATE OF BIRTH (Month, day, and year)
5. DO YOU NOW HOLD, OR HAVE YOU EVER HELD, AN EXAMINER DESIGNATION
TYPE AND NUMBER YES NO 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 MO
ROTORTYPE
TOTAL LAST 12 MO
GLIDERS
TOTAL LAST 12 MO
AIRSHIPS
TOTAL LAST 12 MO
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.
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.
DATE
SIGNATURE
FAA Form 8710-6 (10-95) Supersedes Previous Edition
Electronic Forms (PDF)
NSN: 0052-00-036-7003
FOR FAA USE TYPE OF ACTION ORIGINAL ISSUANCE CERTIFICATES/RATINGS RENEWAL ADDITIONAL AUTHORITY SPOT CHECK ONLYNO RENEWAL EFFECTED REINSTATEMENT PRIVATE PILOT COMMERCIAL PILOT AIRLINE TRANSPORT PILOT INSTRUMENT RATING ADDITIONAL RATINGS PRIVATE COMMERCIAL ATR FLIGHT TEST ACTIVITIES-GENERAL AVIATION
(Complete for renewals and additional designations) TOTAL SUBMITTED DISAPPROVED BY EXAMINER
DATE LAST REPORT SUBMITTED
ACCEPTED BY INSPECTOR 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. CATEGORY
DESIGNATION
PRIVATE PILOT COMMERCIAL PILOT EXAMINER AIRLINE PROFICIENCY PILOT EXAMINER FLIGHT ENGINEER EXAMINER FLIGHT INSTRUCTOR EXAMINER
ADDITIONAL QUALIFICATIONS LIMITATIONS (For pilot flight engineer examiner give aircraft category)
AIRPLANE ROTORCRAFT GLIDER AIRSHIP OFFICE NO. INSPECTOR'S SIGNATURE
DATE
PRIVACY ACT STATEMENT. The information on this form is solicited under authority of the Federal Aviation Regulations Pan 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 your 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.
CONCUR DISAPPROVE TYPE OF DESIGNATION
DATE
REGIONAL OFFICE ACTION SIGNATURE
NO. FAA Form 8710-6 (10-95) Supersedes Previous Edition
Electronic Forms (PDF)
CERTIFICATE OF AUTHORITY ISSUED DO TO SERVE UNDER EXPIRATION DATE NSN: 0052-00-036-7003