Form 8710 Airman Certificate And Rating Application (Page 3 of 4) in pdf

TYPE OR PRINT ALL ENTRIES IN INK

Form Approved OMB No: 2120-0021

Airman Certificate and/or

Rating Application

U.S. Department of Transportation

Federal Aviation Administration

I. Application Information

Student

Recreational

Private

Commercial

Airline Transport

Instrument

Additional Aircraft Rating

Airplane Single-Engine

Airplane Multiengine

Rotorcraft

Glider

Lighter-Than-Air

Flight Instructor

Initial

Renewal

Reinstatement

Additional Instructor Rating

Ground Instructor

Medical Flight Test

Reexamination

Reissuance of

Certificate

Other

A. Name (Last, first, middle)

B. SSN (US Only)

C. Date of Birth

D. Place of Birth

Mo.

Day

Year

E. Address (Please see Instructions Before Completing)

F. Nationality (Citizenship)

Specify

G. Do you read, speak and understand English?

USA

Other

Yes

H. Height

City, State, Zip Code

J. Hair

I. Weight

K. Eyes

L. Sex

Male

In.

Lbs.

Female

M. Do you now hold, or have you ever held an FAA Pilot Certificate?

N. Grade Pilot Certificate

O. Certificate Number

P. Date Issued

Yes

Q. Do you hold a

R. Class of Certificate

T. Name of Examiner

Yes

S. Date Issued

Medical Certificate?

U. Have you been convicted for violation of Federal or State statutes relating to narcotic drugs, marijuana, or depressant

V. Date of Final Conviction

or stimulant drugs or substances

Yes

X. Date

W. Glider or Free Balloon

Signature

Medical Statement: I have no known physical defect which makes

Pilots only:

me unable to pilot a gilder or free balloon.

II. Certificate or Rating Applied For on Basis of:

1. Aircraft to be used (if flight test required)

2a. Total time in this aircraft

2b. Pilot in command

A. Completion of

Required Test

hours

1. Service

2. Date Rated

3. Rank or Grade and Service Number

B. Military

Competence

4. Has flown at least 10 hours as pilot In command during

Obtained in

the past 12 months in the following military aircraft.

1. Name and Location of Training Agency or Training Center

1a Certification Number

C. Graduate of

Approved

2. Curriculum from Which Graduated

3. Date

Course

1. Country

2. Grade or License

3. Number

D. Holder of

Foreign License

4. Ratings

Issued By

1. Name of Air Carrier

2. Date

3. Which Curriculum

E. Completion of Air

Carrier's Approved

Transition

Initial

Upgrade

Training Program

III. Record of Pilot time (Do not write in the shaded areas.)

Total

Instruction

Solo

Pilot

Second

Cross

Instrument

Night

Night Pilot

Night

Number

Received

Country

Instruction

Take-off/

Command

Instruction

Solo

Pilot in

Received

Landing

Command

Landing

Flights

Aero-Tows

Ground

Powered

Free

Received

Command

Pilot in

Launches

Flights

Command

Airplanes

Rotor-

craft

Gliders

Lighter

than Air

Training

Device

Simulator

IV. Have you failed a test for this certificate or rating?

Yes

Within the Past 30 days?

Yes

V. Applicant's Certification

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

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

Signature of Applicant

Date

FAA Use Only

EMP

REG

D.O.

SEAL

CON

ISS

ACT

LEV

S.H.