Verification Of Authenticity Of Foreign License, Rating, And Medical Certification

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Verification of Authenticity of Foreign License, Rating, and Medical Certification
Instructions for completing the form
Basic Airman Information
Block 1. Name as it appears on your pilot certification. Enter your name exactly as it appears on your foreign pilot certificate.
Block 2. SSN (US Only). Optional: See supplemental Information Privacy Act. Do not leave blank. Use only United States Social Security number.
Enter either your US SSN or the words “Do Not Use” or “None”. SSN’s are not shown on certificates.
Block 3. Date of Birth. Enter eight digits; Use numeric characters, i.e. 07-09-1940. Check to see that DOB is the same as it is on the foreign license
and medical certificate.
Block 4. Place of Birth. If you were born in the USA, enter the city and state where you were born. If the city is unknown, enter the county and state.
If you were born outside the USA, enter the name of the city and country where you were born.
Block 5. Permanent Mailing Address. Enter residence number and street, P.O. Box or rural route number in the top part of the block above the line.
The City, State, and Zip code go in the bottom part of the block below the line. FAA policy requires that you use your permanent mailing address. A
map or directions must be provided if a physical address is unavailable. If you require the results of this verification of authenticity mailed to a
temporary address, please submit that information on a separate sheet of paper.
Block 6. Citizenship. Check “Other” and enter the country where you are a citizen or check USA, if applicable.
Block 7. Do you read, speak, write, &understand the English language. Check yes or no.
Block 8. Height. Enter your height in inches. Example: 5’8” would be entered as 68 in. No fractions, use whole inches only.
Block 9. Weight. Enter your weight in pounds. No fractions, use whole pounds only.
Block 10. Hair. Spell out the color of your hair. If bald, enter “Bald”. Color should be listed as black red brown, blond or gray. If you wear a wig or
toupee, enter the color of your hair under the wig or toupee.
Block 11. Eyes. Spell out the color of your eyes. The color should be listed as blue, brown, black, hazel, green or gray.
Block 12. Sex. Check male or female.
Block 13a. Do you now hold, or have you ever held an FAA Pilot Certificate? Check yes or no. (NOTE a student pilot certificate is a Pilot Certificate).
Block 13b. Certificate number. Enter the number of your FAA pilot certificate
Block 13c. Date issued. Enter the date your FAA pilot certificate was issued.
Block 14a. Do you hold a Current Foreign Medical Certificate or Endorsement? Check yes or no.
Block 14b. Class of certificate. Enter the class of the foreign medical certificate or endorsement.
Block 14c. Date issued. Enter the date the foreign medical certificate or endorsement was issued.
Block 14d. Date expired. Enter the expiration date of the foreign medical certificate or endorsement.
Block 14e. Name of Examiner. Enter the name of the person as shown on foreign medical certificate or endorsement.
Block 15a. Do you hold an FAA medical Certificate? Check yes or no.
Block 15b. Class of certificate. Enter the class of the FAA medical certificate.
Block 15c. Date issued. Enter the date the FAA medical certificate was issued.
Block 15d. Date expired. Enter the expiration date of the FAA medical certificate.
Block 15e. Name of Examiner. Enter the name of the person as shown on the FAA medical certificate.
Certificate or Rating Applied for on Basis of:
Block 16. Holder of Foreign License Issued By.
16a. Country. Enter Name of ICAO Country that issued the license.
16b. Grade of License. Enter Grade of license issued, i.e. private, commercial, etc.
16c. Number. Enter number that appears on the license.
16d. Ratings. Enter all ratings that appear on the license.
Block 17. Is your foreign license under an order of revocation or suspension by the foreign country that issued your license? Check yes or no.
Block 18. Please provide the location of the Flight Standards District Office (FSDO) where you intend to make application. Enter the location of the
FSDO from the list provided so your verification can be provided to that FSDO.
Signature of Applicant. Sign your full name.
Enter the date you sign the Verification of Authenticity of Foreign License, Rating, and Medical Certification form.

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