Faa Form 8610-1 Mechanic'S Application For Inspection Authorization-Privacy Act Page 2
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1
2
3No certificate may be issued unless a completed
application form has been received (14 CFR 65).
U. S. DEPARTMENT OF TRANSPORTATION
Form Approved:
OMB No. 2120-0022
FEDERAL AVIATION ADMINISTRATION
MECHANIC’S APPLICATION FOR INSPECTION AUTHORIZATION-PRIVACY ACT
Exp. 09/30/2017
1. NAME
2. MECHANIC CERTIFICATE NO.
(Last, First, Middle)
4a. FIXED BASE OF OPERATIONS
4b. TELEPHONE NO.
3. MAILING ADDRESS
(Number, Street, City, State/County,
Zip Code) (Place at which you desire to receive
PLACE AT WHICH YOU MAY BE LOCATED IN
PLACE AT WHICH YOU MAY
Airworthiness Directives, etc.)
PERSON DURING NORMAL WORKING WEEK
BE LOCATED BY TELEPHONE
DURING NORMAL WORKING
WEEK
YES
NO
5. HAVE YOU HELD A MECHANIC CERTIFICATE WITH BOTH AIRFRAME AND POWERPLANT RATINGS FOR THE 3
YEARS PRECEDING THE DATE OF THIS APPLICATION ?
6. 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 CFRs ?
7. HAS YOUR MECHANIC CERTIFICATE AND/OR RATINGS BEEN REVOKED OR SUSPENDED DURING THE 3-YEAR
PERIOD PRECEDING THIS APPLICATION ?
8. HAS AN INSPECTION AUTHORIZATION BEEN DENIED YOU WITHIN 90 DAYS PREVIOUS TO THIS APPLICATION ?
IF ANSWER IS “YES”, EXPLAIN IN REMARKS.
9. HAVE YOU MET THE MINIMUM REQUIREMENTS FOR RENEWAL OF INSPECTION AUTHORIZATION ?
(For Renewal Only)
10. BASIS FOR RENEWAL
(Number Performed Per Renewal Period)
ALTERATIONS
REPAIRS
ANNUAL INSP.
PROGRESSIVE INSP.
RECENT ISSUANCE –
IN EFFECT LESS THAN 90
First Year
First Year
First Year
First Year
Second Renewal
Second Renewal
Second Renewal
Second Renewal
Period
Period
Period
Period
Period
Period
Period
Period
DAYS BEFORE EXPIRATION
DATE.
FAA ACCEPTED COURSE/SEMINAR NO., LOCATION, AND DATE
FAA ACCEPTED COURSE/SEMINAR NO., LOCATION, AND DATE
(First Year Period)
(Second Renewal Period)
11. AIRCRAFT MAINTENANCE ACTIVITY DURING LAST 2 YEARS
NAME AND ADDRESS OF REPAIR STATION, FACILITY,
DATES
DESCRIPTION OF ACTIVITY
MANUFACTURER, OPERATOR, ETC.
FROM
TO PRESENT
FROM
TO
FROM
TO
12. REMARKS
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)
DATE
INSPECTOR’S SIGNATURE
OFFICE IDENTIFICATION
ENDORSEMENT
DATE
INSPECTOR’S SIGNATURE
OFFICE IDENTIFICATION
ISSUANCE
RENEWAL
VOLUNTARY SURRENDER
FAA Form 8610-1
(07-10) SUPERCEDES PREVIOUS EDITION
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