Airman Certificate And/or Rating Application - Privacy Act (Page 2 of 3) in pdf

TYPE OR PRINT ALL ENTRIES IN INK

Form Approved OMB. No. 2120-0022

U.S. Department of Transportation

Federal Aviation Administration

AIRMAN CERTIFICATE AND/OR RATING APPLICATION

MECHANIC

REPAIRMAN

PARACHUTE RIGGER

AIRFRAME

SENIOR

MASTER

POWERPLANT

SEAT

CHEST

(Specify Rating)

BACK

LAP

APPLICATION FOR:

ORIGINAL ISSUANCE

ADDED RATING

A. NAME (First, Middle, Last)

K. PERMANENT MAILING ADDRESS

B. SOCIAL SECURITY NO.

C. DOB (Mo., Day., Yr.)

D. HEIGHT

E. WEIGHT

NUMBER AND STREET, P.O. BOX, ETC.

IN.

F. HAIR

G. EYES

H. SEX

I. NATIONALITY (Citizenship)

CITY

J. PLACE OF BIRTH

STATE

ZIP CODE

L. HAVE YOU EVER HAD AN AIRMAN CERTIFICATE SUSPENDED OR REVOKED?

M. DO YOU NOW OR HAVE YOU EVER HELD AN FAA AIRMAN

CERTIFICATE?

YES

SPECIFY TYPE:

YES (If "Yes," explain on an attached sheet keying to appropriate item number).

N. HAVE YOU EVER BEEN CONVICTED FOR VIOLATION OF ANY FEDERAL OR STATE STATUTES

DATE OF FINAL CONVICTION

PERTAINING TO NARCOTIC DRUGS, MARIJUANA, AND DEPRESSANT OR STIMULANT

YES

DRUGS OR SUBSTANCES? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

B. MILITARY

C. LETTER OF RECOMMENDATION FOR

A. CIVIL

EXPERIENCE

REPAIRMAN (Attach copy)

(1) NAME AND LOCATION OF SCHOOL

D. GRADUATE

OF APPROVED

(2) SCHOOL NO.

(3) CURRICULUM FROM WHICH GRADUATED

(4) DATE

COURSE

E. STUDENT HAS MADE SATISFACTORY PROGRESS

(1) SCHOOL NAME

NO.

(2) SCHOOL OFFICIAL'S SIGNATURE

AND IS RECOMMENDED TO TAKE THE ORAL/

PRACTICAL TEST (FAR 65.80)

(1) DATE AUTH.

(2) DATE AUTH. EXPIRES (3) FAA INSPECTOR SIGNATURE

(4) FAA DIST OFC.

F. SPECIAL AUTHORIZATION TO TAKE

MECHANIC'S ORAL/PRACTICAL TEST

(FAR 65.80)

(1) SERVICE

(2) RANK OR PAY LEVEL

(3) MILITARY SPECIALITY CODE

A. MILITARY

COMPETANCE

OBTAINED IN

B. APPLICANT'S OTHER THAN FAA CERTIFICATED SCHOOL GRADUATES. LIST EXPERIENCE RELATING TO CERTIFICATE AND RATING APPLIED FOR.

(Continue on separate sheet, if more space is needed).

DATES-MONTH AND YEAR

EMPLOYER AND LOCATION

TYPE WORK PERFORMED

FROM

FOR

PACKED AS A -

SEAT

CHEST

BACK

LAP

MASTER

C. PARACHUTE RIGGER APPLICANTS:

SENIOR

MILITARY

RATING

INDICATE BY TYPE HOW MANY

ONLY

RIGGER

PARACHUTES PACKED

I CERTIFY THAT THE STATEMENTS BY ME ON THIS APPLICATION ARE TRUE

IV. APPLICANT'S

A. SIGNATURE

B. DATE

CERTIFICATION

DATE

INSPECTOR'S SIGNATURE

FAA DISTRICT OFFICE

I FIND THIS APPLICANT MEETS THE EXPER-

IENCE REQUIREMENTS OF FAR 65 AND IS

ELIGIBLE TO TAKE THE REQUIRED TESTS.

FOR FAA USE ONLY

Emp.

.reg.

D.O.

.seal .con iss.

Act

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#rte

Rating (1)

Rating (2)

Rating (3)

Rating (4)

LIMITATIONS

Electronic Version (Adobe)

FAA Form 8610-2

(2-85) SUPERSEDES PREVIOUS EDITION

Airman Certificate And/or Rating Application - Privacy Act Page 2

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