Supplemental Qualifications Statement For 1825 And 2181 Series Faa Form 3330-47-3

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FORM APPROVED OMB NO. 2120-0500
Supplemental Qualifications Statement
U.S. Department of Transportation
FOR 1825 AND 2181 SERIES
Federal Aviation Administration
1. Name
2. Date of
3. Social Security
(First, MI, Last)
4. AIRMAN CERTIFICATES HELD
Birth
Number
Type
Date Issued
Certificate No.
(Mo/Da/Yr)
Airline Transport Pilot
Commercial Pilot
5. PILOT RATING RECORD
Private Pilot
Indicate certificate privileges for the ratings listed
below by writing "A" for Airline Transport, "C" for Commercial or "P" for Private in
Flight Instructor
column 1. Write an "F" for Flight Instructor Rating in column 2, where appropriate
6. TEST PILOT EXPERIENCE
1 2
1 2
Type Ratings: (specify)
Name of Company or Organization
Date Employed
Fixed
Roto-
Airplane Single Engine Land
Glider
Wing
Craft
Airplane Single Engine Sea
Rotorcraft Helicopter
Flight
Hours
Hours
Airplane Multiengine Land
Rotorcraft Gyroplane
Test
Airplane Multiengine Sea
Lighter-than-air Free
Pilot
Instrument Airplane
Balloon
Production
Name of Company or Organization
Date Employed
Hours
Hours
Instrument Helicopter
Lighter-than-air Airship
Test
Pilot
Total Hours Flown to Date
7. FAA DESIGNATIONS
8. TYPE AND TOTAL
9. AIRCRAFT
Total Hours Flown to Date
AND AUTHORIZATIONS
FLIGHT HOURS
Airplane
Rotorcraft
Date Issued
Flt Engr
PIC
SIC
PIC
SIC
Make/Model/Series
PIC
SIC
Designated Pilot Examiner
Total Pilot Time
Pilot Proficiency Examiner
Single Engine
Designated Flight Engineer
Twin Engine
Examiner
Three or more Engine
Multiengine over 12,500 lbs max-
Designated Aircraft Dispatcher
imum Certificated Takeoff Weight
Examiner
Check Airman
Turbine Powered
Aircrew Program Designee
Turbo Powered
Designated Airworthiness
Actual Instrument
Representative
Hood Instrument
Designated Manufacturing
Flight Simulator
Inspection Representative
Night
Designated Engineering
Total Flight Instructor
Representative
Instrument Instructor
Designated Parachute Rigger
Multiengine Instructor
Examiner
Total in Last 12 Months
Total in Last 3 Years
Total in Last 5 Years
FAA Form 3330-47-3 (10/98)

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