Free Mechanic's Application For Inspection Authorization--Privacy Act - Federal

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U.S. DEPARTMENT OF TRANSFORMATION
FEDERAL AVIATION ADMINISTRATION

SUPPLEMENTAL INFORMATION

MECHANIC'S APPLICATION FOR INSPECTION AUTHORIZATION--PRIVACY ACT

Information on FAA form 8610-1, Mechanic's Application for Inspection Authorization is solicited under the authority of 49 U.S.C. 44103 as implemented by 14 CFR Part 65. The purpose of this information is for the issuance and renewal of inspection authorizations. The information will become part of the Privacy Act system of records DOT/FAA 847, Aviation Records on Individuals, and the routine uses of that system will apply. Submission of this The information will only be used by the program office. Authorization or renewal cannot be issued without this information. Paperwork Reduction Act Statement: The information collected on this form is necessary to ensure applicant eligibility. The information is used to determine that the applicant meets the necessary qualifications for an original or renewal Mechanic's Inspection Authorization. We estimate that it will take approximately 20 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 847, Aviation Records on Individuals. 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 2120-0022. 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, AIO-20.

FAA Form 8610-1 (2-78) SUPERSEDES PREVIOUS EDITION
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No certificate may be issued unless a completed application form has been received (14 C.F.R. 65)

U.S. DEPARTMENT OF TRANSPORTATION
FEDERAL AVIATION ADMINISTRATION

MECHANIC'S APPLICATION FOR INSPECTION AUTHORIZATION--PRIVACY ACT
1. NAME (Last, first, middle)

Form Approved: OMB No. 2120-0022 11/30/07
2. MECHANIC CERTIFICATE NO.

3. MAILING ADDRESS (Number, street, city, State/County, ZIP Code) (Place at which you desire to receive Airworthiness Directives, etc.)

4a. FIXED BASE OF OPERATIONS PLACE AT WHICH YOU MAY BE LOCATED IN PERSON DURING NORMAL WORKING WEEK

4b. TELEPHONE NO. PLACE AT WHICH YOU MAY BE LOCATED BY TELEPHONE DURING NORMAL WORKING WEEK

5. 6. 7. 8. 9.

HAVE YOU HELD A MECHANIC CERTIFICATE WITH BOTH AIRFRAME AND POWERPLANT RATINGS FOR THE 3 YEARSPRECEDING THE DATE OF THIS APPLICATION? HAVE YOU BEEN ACTIVELY ENGAGED, FOR AT LEAST THE 2-YEAR PERIOD BEFORE THE DATE OF APPLICATION IN MAINTAINING AIRCRAFT CERTIFICATED AND MAINTAINED IN ACCORDANCE WITH THE FARS? HAS YOUR MECHANIC CERTIFICATE AND/OR RATINGS BEEN REVOKED OR SUSPENDED DURING THE 3--YEAR PERIOD PRECEDING THIS APPLICATION? HAS AN INSPECTION AUTHORIZATION BEEN DENIED YOU WITHIN 90 DAYS PREVIOUS TO THIS APPLICATION? IF ANSWER IS "YES", EXPLAIN IN REMARKS. HAVE YOU MET THE MINIMUM REQUIREMENTS FOR RENEWAL OF INSPECTION AUTHORIZATION? (For Renewal Only) 10. BASIS FOR RENEWAL (Number Performed)

YES

NO

ALTERATIONS

REPAIRS

ANNUAL INSPECTIONS

PROGRESSIVE INSPECTIONS

RECENT ISSUANCE-IN EFFECT LESS THAN 90 DAYS BEFORE EXPIRATION DATE

11. AIRCRAFT MAINTENANCE ACTIVITY DURING LAST 2 YEARS DATES FROM TO PRESENT FROM TO FROM TO FROM TO 12. REMARKS NAME AND ADDRESS OF REPAIR STATION, FACILITY, MANUFACTURER, OPERATOR, ETC. DESCRIPTION OF ACTIVITY

13. CERTIFICATION: I certify that the statements made above and in all attachments hereto are correct and true. DATE SIGNATURE OF APPLICANT

14. RECORD OF ACTION (For FAA use only) ISSUANCE ENDORSEMENT VOLUNTARY SURRENDER RENEWAL INSPECTOR'S SIGNATURE OFFICE IDENTIFICATION

FAA Form 8610-1 (2-78) SUPERSEDES PREVIOUS EDITION