Form Afs-760-Exam-02 - Verification Of Authenticity Of Foreign License, Rating, And Medical Certification Page 2

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Verification of Authenticity of Foreign License, Rating, and Medical Certification

Privacy Act

The information on the accompanying form is solicited under authority of Title 14 of the Code of Federal Regulations (14 CFR), Part 61. The purpose of

this data is to be used to identify and evaluate your qualifications and eligibility for the issuance of an airman certificate and/or rating. Submission of all

requested data is mandatory, except for the Social Security Number (SSN) which is voluntary. Failure to provide all the required information would result

in you not being issued a certificate and/or rating. The information would become part of the Privacy Act system of records DOT/FAA 847, General Air

Transportation Records on Individuals. The information collected on this form would be subject to the published routine uses of DOT/FAA 847. Those

routine uses are: (a) To provide basic airmen certification and qualification information to the public upon request. (b) To disclose information to the

National Transportation Safety Board (NTSB) in connection with its investigation responsibilities. (c) To provide information about airmen to Federal,

state, and local law enforcement agencies when engaged in the investigation and apprehension of drug violators. (d) To provide information about

enforcement actions arising out of violations of the Federal Aviation regulations to government agencies, the aviation industry, and the public upon

request. (e) To disclose information to another Federal agency, or to a court or an administrative tribunal, when the Government or one of its agencies

is a party to a judicial proceeding before the court or involved in administrative proceedings before the tribunal.

Basic Airman Information

1. Name as it appears on your foreign license.

2. Date of Birth

3. Place of Birth

Last

First

Middle

Month

Day

Year

4. Address you want your copy of the verification letter mailed to.

5. City, State, Zip Code (Country if applicable)

6. Citizenship

7a. Do you hold a Current Foreign

7b. Class of Certificate

7c. Date Issued

7d. Date Expired

7e. Name o f Examiner

Medical Certificate or Endorsement?

Yes

Certificate or Rating Applied For on Basis of:

8 a. Country

8 b. Grade of License

8 c. Number

8. Holder of a Foreign

License Issued By

8 d. Ratings (Enter all ratings that appear on your foreign license)

9. Is your foreign license under an order of revocation or suspension by the foreign country that issued your license?

Yes

10. Please provide the location of the Flight Standards District Office (FSDO) where you intend to make application. (Select FAA FSDO from list provided.

Please do not provide location of flight school, employer, or Airmen Certification Branch, AFS-760.)

I hereby authorize the issuing CAA to provide all pertinent information to the FAA.

EMAIL Address

Signature of Applicant

Telephone Number where you can be reached.

Date

Attachments:

Copy of Foreign License

Copy of English Transcription of License

Copy of Medical Certificate or Endorsement

AFS-760-Exam-02 (7/04)