Application For Airman Medical Certificate Faa 8500-8 printable pdf download

Instructions for Completion of the Application for Airman Medical Certificate

or Airman Medical and Student Pilot Certificate, FAA Form 8500-8

Applicant must fill in completely numbers 1 through 20 of the application using a ballpoint pen. Exert sufficient pressure to make legible copies. The

following numbered instructions apply to the numbered headings on the application form that follows this page.

NOTICE -- Intentional falsification may result in federal criminal prosecution. Intentional falsification may also result in suspension or revocation of all

airman, ground instructor, and medical certificates and ratings held by you, as well as denial of this application for medical certification.

1. APPLICATION FOR -- Check the appropriate box.

"Substance dependence" is defined by any of the following:

increased tolerance; withdrawal symptoms; impaired control of use;

2. CLASS OF AIRMAN MEDICAL CERTIFICATE APPLIED FOR --

or continued use despite damage to health or impairment of social,

Check the appropriate box for the class of airman medical certificate

personal, or occupational functioning. "Substance abuse" includes

for which you are making application.

the following: use of an illegal substance; use of a substance or

3. FULL NAME -- If your name has changed for any reason, list

substances in situations in which such use is physically hazardous;

current name on the application and list any former name(s) in the

or misuse of a substance when such misuse has impaired health or

EXPLANATIONS box of number 18 on the application.

social or occupational functioning. "Substances" include alcohol,

4. SOCIAL SECURITY NUMBER -- The social security number is

PCP, marijuana, cocaine, amphetamines, barbiturates, opiates, and

optional; however, its use as a unique identifier does eliminate

other psychoactive chemicals.

mistakes.

Conviction and/or Administrative Action History -- Letter (v) of this

5. ADDRESS -- Give permanent mailing address and country.

subheading asks if you have ever been: (1) convicted (which may

Include your complete nine digit ZIP code if known. Provide your

include paying a fine, or forfeiting bond or collateral) of an offense

current area code and telephone number.

involving driving while intoxicated by, while impaired by, or while

6. DATE OF BIRTH -- Specify month (MM), day (DD), and year

under the influence of alcohol or a drug; or (2) convicted or subject

(YYYY) in numerals; e.g., 01/31/1950. Indicate citizenship; e.g.,

to an administrative action by a state or other jurisdiction for an

U.S.A.

offense for which your license was denied, suspended, cancelled, or

7. COLOR OF HAIR -- Specify as brown, black, blond, gray, or red.

revoked or which resulted in attendance at an educational or

If bald, so state. Do not abbreviate.

rehabilitation program. Individual traffic convictions are not required

8. COLOR OF EYES -- Specify actual eye color as brown, black,

to be reported if they did not involve: alcohol or a drug; suspension,

blue, hazel, gray, or green. Do not abbreviate.

revocation, cancellation, or denial of driving privileges; or attendance

at an educational or rehabilitation program. If "yes" is checked, a

9. SEX -- Indicate male or female.

description of the conviction(s) and/or administrative action(s) must

10. TYPE OF AIRMAN CERTIFICATE(S) YOU HOLD -- Check appli-

be given in the EXPLANATIONS box. The description must include:

cable block(s). If "Other" is checked, provide name of certificate.

(1) the alcohol or drug offense for which you were convicted or the

11. OCCUPATION -- Indicate major employment. "Pilot" will be

type of administrative action involved (e.g., attendance at an alcohol

used only for those gaining their livelihood by flying.

treatment program in lieu of conviction; license denial, suspension,

12. EMPLOYER -- Provide your employer's full name. If self-

cancellation, or revocation for refusal to be tested; educational safe

employed, so state.

driving program for multiple speeding convictions; etc.); (2) the name

of the state or other jurisdiction involved; and (3) the date of the

13. HAS YOUR FAA AIRMAN MEDICAL CERTIFICATE EVER

conviction and/or administrative action. The FAA may check state

BEEN DENIED, SUSPENDED, OR REVOKED -- If "yes" is checked,

motor vehicle driver licensing records to verify your responses. Letter

give month and year of action in numerals.

(w) of this subheading asks if you have ever had any other (nontraffic)

14. TOTAL PILOT TIME TO DATE -- Give total number of civilian

convictions (e.g., assault, battery, public intoxication, robbery, etc.).

flight hours. Indicate whether logged or estimated. Abbreviate as

If so, name the charge for which you were convicted and the date of

Log. or Est.

conviction in the EXPLANATIONS box. See NOTE below.

15. TOTAL PILOT TIME PAST 6 MONTHS -- Give number of civilian

flight hours in the 6-month period immediately preceding date of this

19. VISITS TO HEALTH PROFESSIONAL WITHIN LAST 3 YEARS --

application. Indicate whether logged or estimated. Abbreviate as

List all visits in the last 3 years to a physician, physician assistant,

Log. or Est.

nurse practitioner, psychologist, clinical social worker, or substance

16. MONTH AND YEAR OF LAST FAA MEDICAL EXAMINATION --

abuse specialist for treatment, examination, or medical/mental

Give month and year in numerals. If none, so state.

evaluation. List visits for counseling only if related to a personal

substance abuse or psychiatric condition. Give date, name, address,

17a. DO YOU CURRENTLY USE ANY MEDICATION (Prescription

and type of health professional consulted and briefly state reason for

or Nonprescription) -- Check "yes" or "no." If "yes" is checked, give

consultation. Multiple visits to one health professional for the same

name of medication(s) and indicate if the medication was listed in a

condition may be aggregated on one line. Routine dental, eye, and

previous FAA medical examination. See NOTE below.

FAA periodic medical examinations and consultations with your

17b. Indicate whether you use near vision contact lens(es) while

employer-sponsored employee assistance program (EAP) may be

flying.

excluded unless the consultations were for your substance abuse or

18. MEDICAL HISTORY -- Each item under this heading must be

unless the consultations resulted in referral for psychiatric evaluation

checked either "yes" or "no." You must answer "yes" for every condition

or treatment. See NOTE below.

you have ever been diagnosed with, had, or presently have and

describe the condition and approximate date in the EXPLANATIONS

20. APPLICANT'S DECLARATION -- Two declarations are contained

block.

under this heading. The first authorizes the National Driver Register

If information has been reported on a previous application for airman

to release adverse driver history information, if any, about the

medical certificate and there has been no change in your condition,

applicant to the FAA. The second certifies the completeness and

you may note "PREVIOUSLY REPORTED, NO CHANGE" in the EX-

truthfulness of the applicant's responses on the medical application.

PLANATIONS box, but you must still check "yes" to the condition. Do

The declaration section must be signed and dated by the applicant

not report occasional common illnesses such as colds or sore throats.

after the applicant has read it.

NOTE: If more space is required to respond to "yes" answers for numbers 17, 18, or 19, use a plain sheet of paper

bearing the information, your signature, and the date signed.

Applicant -- Please Tear Off This Sheet After Completing The Application Form.

FAA Form 8500-8 (3-99) Supersedes Previous Edition

NSN: 0052-00-670-6002

Application For Airman Medical Certificate Faa 8500-8

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