Application For Airman Medical Certificate Faa 8500-8 (Page 2 of 3) in pdf

Applicant Must Complete ALL 20 Items (Except For Shaded Areas) PLEASE PRINT

Form Approved OMB NO. 2120-0034

FF-

Copy of FAA Form 8500-8

1. Application For:

2. Class of Medical Certificate Applied For:

1953420

(Medical Certificate) or FAA

Airman Medical and

Airman Medical

1st

2nd

3rd

Form B420-2 Medical/Student

Student Pilot Certificate

Certificate

Pilot Certificate) issued.

3. Last Name

First Name

Middle Name

MEDICAL CERTIFICATE___________CLASS

AND STUDENT PILOT CERTIFICATE

4. Social Security Number

This certifies that (Full name and address):

5. Address

Telephone Number (

)

Number / Street

City

State / Country

Zip Code

6. Date of Birth

7. Color of Hair 8. Color of Eyes

9. Sex

M M / D D / Y Y Y Y

Date of Birth

Height Weight

Hair

Eyes

Sex

Citizenship

10. Type of Airman Certificate(s) You Hold:

has met the medical standards prescribed in part 67, Federal

None

ATC Specialist

Flight Instructor

Recreational

Aviation Regulations, for this class of Medical Certificate.

Airline Transport

Flight Engineer

Private

Other

Commercial

Flight Navigator

Student

11. Occupaton

12. Employer

13. Has Your FAA Airman Medical Certificate Ever Been Denied, Suspended, or Revoked?

Yes

If yes, give date

M M / D D / Y Y Y Y

16. Date of Last FAA Medical Application

Total Pilot Time

(Civilian Only)

14. To Date

15. Past 6 months

Date of Examination

Examiner's Designation No.

No Prior

Application

M M / D D / Y Y Y Y

17a. Do You Currently Use Any Medication (Prescription or Nonprescription)?

Signature

Yes

(If yes, below list medication(s) used and check appropriate box).

Previously Reported

Yes

Typed Name

AIRMAN'S SIGNATURE

(If more space is required, see 17.a. on the instruction sheet).

17.b. Do You Ever Use Near Vision Contact Lens(es) While Flying?

Yes

18. Medical History - HAVE YOU EVER IN YOUR LIFE BEEN DIAGNOSED WITH, HAD, OR DO YOU PRESENTLY HAVE ANY OF THE FOLLOWING?

Answer "yes" or "no"

for every condition listed below. In the EXPLANATIONS box below, you may note "PREVIOUSLY REPORTED, NO CHANGE" only if the explanation of the condition was

reported on a previous application for an airman medical certificate and there has been no change in your condition. See instructions Page

Yes

Condition

Yes

Condition

Yes

Condition

Yes

Condition

Mental disorders of any sort;

Frequent or severe headaches

Heart or vascular trouble

Military medical discharge

depression, anxiety, etc.

Substance dependence or failed a

Dizziness or fainting spell

High or low blood pressure

Medical rejection by military service

drug test ever, or susbstance abuse

or use of illegal substance in the

Unconsciousness for any reason

Stomach, liver, or intestinal trouble

Rejection for life or health insurance

last 2 years.

Eye or vision trouble except glasses

Kidney stone or blood in urine

Alcohol dependence or abuse

Admission to hospital

Hay fever or allergy

Diabetes

Suicide attempt

Other illness, disability, or surgery

Neurological disorders; epilepsy,

Motion sickness requiring

Asthma or lung disease

seizures, stroke, paralysis, etc.

medication

Conviction and/or Administrative Action History — See Instructions Page

Yes

History of (1) any conviction(s) involving driving while intoxicated by, while impaired by, or while

History of nontraffic

under the influence of alcohol or a drug; or (2) history of any conviction(s) or administrative action(s)

conviction(s)

involving an offense(s) which resulted in the denial, suspension, cancellation, or revocation of driving

(misdemeanors or felonies).

privileges or which resulted in attendance at an educational or a rehabilitation program.

Explanations:

See Instructions Page

FOR FAA USE

Review Action Codes

Yes

(Explain Below)

19. Visits to Health Professional Within Last 3 Years.

See Instructions Page

Date

Name, Address, and Type of Health Professional Consulted

Reason

— NOTICE —

20. Applicant's National Driver Register and Certifying Declarations

Whoever in any matter within the

I hereby authorize the National Driver Register (NDR), through a designated State Department of Motor Vehicles, to furnish to the FAA

jurisdiction of any department or

information pertaining to my driving record. This consent constitutes authorization for a single access to the information contained in the NDR to

a g e n c y o f t h e U n i t e d S t a t e s

verify information provided in this application. Upon my request, the FAA shall make the information received from the NDR, if any, available for

knowingly and willfully falsifies,

my review and written comment. Authority: 23 U.S. Code 401, Note.

conceals or covers up by any trick,

NOTE: ALL persons using this form must sign it. NDR consent, however, does not apply unless this form is used as an

scheme, or device a material fact,

application for Medical Certificate or Medical Certificate and Student Pilot Certificate.

or who makes any false, fictitious or

I hereby certify that all statements and answers provided by me on this application form are complete and true to the best of my knowledge, and

fraudulent statements or repre-

I agree that they are to be considered part of the basis for issuance of any FAA certificate to me. I have also read and understand the Privacy Act

sentations, or entry, may be fined

statement that accompanies this form.

up to $250,000 or imprisoned not

more than 5 years, or both.

Signature of Applicant

Date

(18 U.S. Code Secs. 1001; 3571)

M M / D D / Y Y Y Y

FAA Form 8500-8 (3-00) Supersedes Previous Edition

NSN-0052-00-670-6002

Application For Airman Medical Certificate Faa 8500-8 Page 2

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