Verification Of Authenticity Of Foreign License, Rating, And Medical Certification (Page 2 of 2) in pdf

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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.

Submission of your Social Security Number is voluntary. Disclosure of your SSN will facilitate maintenance of your records which

are maintained in alphabetical order and cross-referenced with your SSN and airman certificate number to provide prompt access.

In the event of nondisclosure, a unique number will be assigned to your file.

Basic Airman Information

1. Name as it appears on your pilot certification

2. SSN (US Only)

3. Date of Birth

4. Place of Birth

Month

Day

Year

5. Address

6. Citizenship

Specify

7. Do you read, speak, write, & understand

the English language?

USA

Yes

Other

City, State, Zip Code

8. Height

9. Weight

10. Hair

11. Eyes

12. Sex

Male

Female

13 a. Do you now hold, or have you ever held an FAA Pilot

13 b. Certificate Number

13 c. Date Issued

Certificate?

Yes

14 a. Do you hold a Current Foreign

14 b. Class of Certificate

14 c. Date Issued

14 d. Date Expired

14 e. Name of Examiner

Medical Certificate or Endorsement?

Yes

15 a. Do you hold an FAA Medical

15 b. Class of Certificate

15 c. Date Issued

15 d. Date Expired

15 e. Name of Examiner

Certificate?

Yes

Certificate or Rating Applied For on Basis of:

16 a. Country

16 b. Grade of License

16 c. Number

16. Holder of a Current

Medical

Foreign License

16 d. Ratings

Issued By

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

Yes

Please provide the location of the Flight Standards District Office (FSDO) where you intend to make application.

18.

Signature of Applicant

Date

Verification Of Authenticity Of Foreign License, Rating, And Medical Certification Page 2

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