Fillable FAA Form 8710-1 Airman Certificate and Rating Application pdf

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FAA Form 8710-1 Airman Certificate and Rating Application pdf

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U.S. Department
of Transportation
Federal Aviation
Administration
FAA Form 8710-1, Airman Certificate
and/or Rating Application
Supplemental Information and Instructions
Paperwork Reduction Act Statement:
The information collected on this form is necessary to determine applicant eligibility for airman ratings. We estimate it
will take 15 minutes to complete this form. The information collected is required to obtain a benefit and becomes part of
the Privacy Act system of records DOT/FAA 847, Aviation Records on Individuals. Please note that an agency may not
conduct or sponsor, and a person is not required to respond to, a collection of information unless it
displays a currently valid
OMB control number. The OMB control number associated with this collection is 2120-0021.
Comments concerning the accuracy of this burden and suggestions for reducing the burden should be directed to the
FAA at: 800 Independence Ave. SW, Washington, DC 20591, Attn: Information Collection Clearance Officer, AES-200.
See Privacy Act Information below. Detach this part before submitting form.
Instructions for completing this form (FAA 8710-1) are below.
If an electronic form is not printed on a duplex printer, the applicant's name, date of birth, and certificate number
(if applicable) must be furnished on the reverse side of the application. This information is required for identification
purposes. The telephone number and E-mail address are optional.
Tear off this cover sheet before submitting this form.
FAA Form 8710-1 (4-00) Supersedes Previous Edition NSN: 0052-00-682-5007
PRIVACY ACT STATEMENT: This statement is provided pursuant to the Privacy Act of 1974, 5 USC § 552a:
The authority for collecting this information is contained in 49 U.S.C. §§ 40113, 44702, 44703, 44709 and 14 C.F.R. Part 6 1 and 65. The principal purpose for which the informa-
tion is intended to be used is to identify and evaluate your qualifications and eligibility for the issuance of an airman certificate and/or rating. Submission of the data is mandatory,
except for the Social Security Number, which is voluntary. Failure to provide all required information will result in our being unable to issue you a certificate and/or rating. The
information collected on this form will be included in a Privacy Act System of Records known as DOT/FAA 847, titled “Aviation Records on Individuals” and will be subject to
the routine uses published in the System of Records Notice (SORN) for DOT/FAA 847 (see www.dot.gov/privacy/privacyactnotices), including:
(a) Providing basic airmen certification and qualification information to the public upon request; examples of basic information include:
• The type of certificates and ratings held, limitations, date of issuance and certificate number;
• The status of the airman’s certificate (i.e., whether it is current or has been amended, modified, suspended or revoked for any reason);
• The airman’s home address, unless requested by the airman to be withheld from public disclosure per 49 U.S.C. 44703(c);
• Information relating to an airman’s physical status or condition used to determine statistically the validity of FAA medical standards; and the date, class, and restrictions of the
latest physical
• Information relating to an individual’s eligibility for medical certification, requests for exemption from medical requirements, and requests for review of certificate denials.
(b) Using contact information to inform airmen of meetings and seminars conducted by the FAA regarding aviation safety.
(c) Disclosing information to the National Transportation Safety Board (NTSB) in connection with its investigation responsibilities.
(d) Providing information about airmen to Federal, State, local and tribal law enforcement agencies when engaged in an official investigation in which an airman is involved.
(e) Providing information about enforcement actions, or orders issued thereunder, to Federal agencies, the aviation industry, and the public upon request.
(f) Making records of delinquent civil penalties owed to the FAA available to the U.S. Department of the Treasury and the U.S. Department of Justice (DOJ) for collection pursu-
ant to 31 U.S.C. 3711(g).
(g) Making records of effective orders against the certificates of airmen available to their employers if the airmen use the affected certificates to perform job responsibilities for
those employers.
(h) Making airmen records available to users of FAA’s Safety Performance Analysis System (SPAS), including the Department of Defense Commercial Airlift Division’s Air Car-
rier Analysis Support System (ACAS) for its use in identifying safety hazards and risk areas, targeting inspection efforts for certificate holders of greatest risk, and monitoring the
effectiveness of targeted oversight actions.
(i) Making records of an individual’s positive drug test result, alcohol test result of 0.04 or greater breath alcohol concentration, or refusal to submit to testing required under a
DOT-required testing program, available to third parties, including current and prospective employers of such individuals. Such records also contain the names and titles of indi-
viduals who, in their commercial capacity, administer the drug and alcohol testing programs of aviation entities.
(j) Providing information about airmen through the Civil Aviation Registry’s Comprehensive Airmen Information System to the Department of Health and Human Services, Office
of Child Support Enforcement, and the Federal Parent Locator Service that locates noncustodial parents who owe child support. Records in this system are used to identify airmen
to the child support agencies nationwide in enforcing child support obligations, establishing paternity, establishing and modifying support orders and location of obligors. Records
listed within the section
on Categories of Records are retrieved using Connect: Direct through the Social Security Administration’s secure environment.
(k) Making personally identifiable information about airmen available to other Federal agencies for the purpose of verifying the accuracy and completeness of medical information
provided to FAA in connection with applications for airmen medical certification.
(l) Making records of past airman medical certification history data available to Aviation Medical Examiners (AMEs) on a routine basis so that AMEs may render the best medical
certification decision.
(m) Making airman, aircraft and operator record elements available to users of FAA’s Skywatch system, including the Department of Defense (DoD), the Department of Homeland
Security (DHS), DOJ and other authorized Federal agencies, for their use in managing, tracking and reporting aviation-related security events.
(n) Other possible routine uses published in the Federal Register (see Prefatory Statement of General Routine Uses for additional uses (65 F.R. 19477-78) For example, a record from
this system of records may be disclosed to the United States Coast Guard (Coast Guard) and to the Transportation Security Administration (TSA) if information from this system
was shared with either agency when that agency was a component of the Department of Transportation (DOT) before its transfer to DHS and such disclosure is necessary to
accomplish a DOT, TSA or Coast Guard function related to this system of records.
AIRMAN CERTIFICATE AND/OR RATING APPLICATION
FAA Form 8710-1 (4-00) Supersedes Previous Edition
AIRMAN CERTIFICATE AND/OR RATING APPLICATION
INSTRUCTIONS FOR COMPLETING FAA FORM 8710-1
I. APPLICATION INFORMATION. Check appropriate blocks(s).
Block A. Name. Enter legal name. Use no more than one middle name for
record purposes. Do not change the name on subsequent applications unless it
is done in accordance with 14 CFR Section 61.25. If you do not have a
middle name, enter “NMN”. If you have a middle initial only, indicate
“Initial only.” If you are a Jr., or a II, or III, so indicate. If you have an FAA
certificate, the name on the application should be the same as the name on the
certificate unless you have had it changed in accordance with 14 CFR Section
61.25.
Block B. Social Security Number. Optional: See supplemental
Information Privacy Act. Do not leave blank: Use only US Social Security
Number. Enter either “SSN” or the words “Do not Use” or “None.” SSN’s
are not shown on certificates.
Block C. Date of Birth. Check for accuracy. Enter eight digits; Use
numeric characters, i.e., 07-09-1925 instead of July 9, 1925. Check to see that
DOB is the same as it is on the medical certificate.
Block D. 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 E. 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. Check for accuracy. Make sure the numbers are not transposed.
FAA policy requires that you use your permanent mailing address.
Justification must be provided on a separate sheet of paper signed and
submitted with the application when a PO Box or rural route number is
used in place of your permanent physical address. A map or directions
must be provided if a physical address is unavailable.
Block F. Citizenship. Check USA if applicable. If not, enter the country
where you are a citizen.
Block G. Do you read, speak, write and understand the English
language? Check yes or no.
Block H. Height. Enter your height in inches. Example: 5’8” would be
entered as 68 in. No fractions, use whole inches only.
Block I. Weight. Enter your weight in pounds. No fractions, use whole
pounds only.
Block J. 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 K. Eyes. Spell out the color of your eyes. The color should be listed
as blue, brown, black, hazel, green, or gray.
Block L. Sex. Check male or female.
Block M. 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 N. Grade of Pilot Certificate. Enter the grade of pilot certificate
(i.e., Student, Recreational, Private, Commercial, or ATP). Do NOT enter
flight instructor certificate information.
Block O. Certificate Number. Enter the number as it appears on your
pilot certificate.
Block P. Date Issued. Enter the date your pilot certificate was issued.
Block Q. Do You Now Hold A Medical Certificate? Check yes or
no. If yes, complete Blocks R, S, and T.
Block R. Class of Certificate. Enter the class as shown on the medical
certificate, i.e., 1
st
, 2
nd
, or 3
rd
class.
Block S. Date Issued. Enter the date your medical certificate was issued.
Block T. Name of Examiner. Enter the name as shown on medical
certificate.
Block U. Narcotics, Drugs. Check appropriate block. Only check “Yes”
if you have actually been convicted. If you have been charged with a
violation which has not been adjudicated, check .“No”.
Block V. Date of Final Conviction. If block “U” was checked “Yes”
give the date of final conviction.
II. CERTIFICATE OR RATING APPLIED FOR ON BASIS OF:
Block A. Completion of Required Test.
1. AIRCRAFT TO BE USED. (If flight test required) – Enter the make and
model of each aircraft used. If simulator or FTD, indicate.
2. TOTAL TIME IN THIS AIRCRAFT (Hrs.) – (a) Enter the total Flight
Time in each make and model. (b) Pilot-In-Command Flight Time - In
each make and model.
Block B. Military Competence Obtained In. Enter your branch of
service, date rated as a military pilot, your rank, or grade and service number.
In block 4a or 4b, enter the make and model of each military aircraft used to
qualify (as appropriate).
Block C. Graduate of Approved Course.
1. NAME AND LOCATION OF TRAINING AGENCY/CENTER.
As shown on the graduation certificate. Be sure the location is entered.
2. AGENCY SCHOOL/CENTER CERTIFICATION NUMBER. As shown
on the graduation certificate. Indicat
e if 142 training center.
3. CURRICULUM FROM WHICH GRADUATED.
As shown on the
graduation certificate.
4. DATE.
Date of graduation from indicated course. Approved course
graduate must also complete Block “A” COMPLETION OF REQUIRED
TEST.
Block D. Holder of Foreign License Issued By.
1. COUNTRY. Country which issued the license.
2. GRADE OF LICENSE. Grade of license issued, i.e., private, commercial,
etc.
3. NUMBER. Number which appears on the license.
4. RATINGS. All ratings that appear on the license.
Block E. Completion of Air Carrier’s Approved Training
Program.
1. Name of Air Carrier.
2. Date program was completed.
3. Identify the Training Curriculum.
III. RECORD OF PILOT TIME. The minimum pilot experience required
by the appropriate regulation must be entered. It is recommended, however,
that ALL pilot time be entered. If decimal points are used, be sure they are
legible. Night flying must be entered when required. You should fill in the
blocks that apply and ignore the blocks that do not. Second In Command
“SIC” time used may be entered in the appropriate blocks. Flight Simulator,
Flight Training Device and PCATD time may be entered in the boxes
provided. Total, Instruction received, and Instrument Time should be entered
in the top, middle, or bottom of the boxes provided as appropriate.
IV. HAVE YOU FAILED A TEST FOR THIS CERTIFICATE OR
RATING?
Check appropriate block.
V. APPLICANT’S CERTIFICATION.
A. SIGNATURE. The way you normally sign your name.
B. DATE. The date you sign the application.
FAA Form 8710-1 (4-00) Supersedes Previous Edition NSN: 0052-00-682-5007
Form Approved OMB No: 2120-0021
TYPE OR PRINT ALL ENTRIES IN INK
09/30/2010
DEPARTMENT OF TRANSPORTATION
FEDERAL AVIATION ADMINISTRATION
Airman Certificate and/or Rating Application
l Application Information
Additional Rating
Flight Instructor ____ Initial ____ Renewal ____ Reinstatement
Medical Flight Test
Student
Airplane Single-Engine
Reexamination
Recreational Private Commercial Airline Transport Instrument
Airplane Multiengine Rotorcraft Balloon Airship Glider Powered-Lift
Additional Instructor Rating
Reissuance of ____________________________ certificate
Ground Instructor
Other ______________________
A. Name (Last, First, Middle) B. SSN (US Only) C. Date of Birth
Month Day Year
D. Place of Birth
E. Address
City, State, Zip Code
F. Citizenship
USA Other ________________
Specify G. Do you read, speak, write, & understand
the English language?
Yes
No
H. Height I. Weight J. Hair K. Eyes L. Sex
Male
Female
M. Do you now hold, or have you ever held an FAA Pilot Certificate?
Yes No
N. Grade Pilot Certificate O. Certificate Number P. Date Issued
Q. Do you hold a
Medical Certificate?
Yes
No
R. Class of Certificate S. Date Issued T. Name of Examiner
U. Have you ever been convicted for violation of any Federal or State statutes relating to narcotic drugs, marijuana, or depressant or stimulant drugs or substances?
Yes No
V. Date of Final Conviction
II. Certificate or Rating Applied For on Basis of:
A.
Completion of
Required Test
1. Aircraft to be used (if flight test required) 2a. Total time in this aircraft / SIM / FTD
hours
2b. Pilot in command
hours
B.
Military
Competence
Obtained In
1. Service 2. Date Rated 3. Rank or Grade and Service Number
4a. Flown 10 hours PIC in last 12 months in the following Military Aircraft. 4b. US Military PIC & Instrument check in last 12 months (List Aircraft)
C.
Graduate of
Approved
Course
1. Name and Location of Training Agency or Training Center 1a. Certification Number
2. Curriculum From Which Graduated 3. Date
D.
Holder of Foreign
License
Issued By
1. Country 2. Grade of License 3. Number
4. Ratings
E.
Completion of Air
Carrier's Approved
Training Program
1. Name of Air Carrier 2. Date 3. Which Curriculum
Initial Upgrade Transition
III RECORD OF PILOT TIME (Do not write in the shaded areas.)
Total
Instruction
Received
Solo
Pilot
in
Command
(PIC)
Cross
Country
Instruction
Received
Cross
Country Solo
Cross
Country PIC
Instrument
Night
Instruction
Received
Night
Take-off/
Landings
Night PIC
Night
Take-Off/
Landing PIC
Number of
Flights
Number of
Aero-Tows
Number of
Ground
Launches
Number of
Powered
Launches
Airplanes
PIC
SIC
PIC
SIC
PIC
SIC
PIC
SIC
Rotor-
craft
PIC
SIC
PIC
SIC
PIC
SIC
PIC
SIC
Powered
Lift
PIC
SIC
PIC
SIC
PIC
SIC
PIC
SIC
Gliders
Lighter
Than Air
Simulator
Training
Device
PCATD
IV. Have you failed a test for this certificate or rating?
Yes No
V. Applicants'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 Form 8710-1 (4-00) Supersedes Previous Edition
NSN: 0052-00-682-5007
Instructor's Recommendation
I have personally instructed the applicant and consider this person ready to take the test.
Date Instructor's Signature (Print Name & Sign) Certificate No: Certificate Expires
Air Agency's Recommendation
The applicant has successfully completed our _________________________________________________________course, and is recommended for certification or rating
without further _____________________________________________test.
Date Agency Name and Number Officials Signature
Title
Designated Examiner or Airman Certification Representative Report
Student Pilot Certificate Issued (Copy attached)
I have personally reviewed this applicant's pilot logbook and/or training record, and certify that the individual meets the pertinent requirements
of 14 CFR Part 61 for the certificate or rating sought.
I have personally reviewed this applicant's graduation certificate, and found it to be appropriate and in order, and have returned the certificate.
I have personally tested and/or verified this applicant in accordance with pertinent procedures and standards with the result indicated below.
Approved -- Temporary Certificate Issued (Original Attached)
Disapproved -- Disapproval Notice Issued (Original Attached)
Location of Test (Facility, City, State) Duration of Test
Ground Simulator/FTD Flight
Certificate or Rating for Which Tested Type(s) of Aircraft Used Registration No.(s)
Date Examiner's Signature (Print Name & Sign) Certificate No. Designation No.
Designation Expires
Evaluator's Record (Use For ATP Certificate and/or Type Ratings)
Inspector Examiner Signature and Certificate Number Date
Oral _______________________________________________________________ __________________________
Approved Simulator/Training Device Check _______________________________________________________________ __________________________
Aircraft Flight Check _______________________________________________________________ __________________________
Advanced Qualification Program _______________________________________________________________ __________________________
Aviation Safety Inspector or Technician Report
I have personally tested this applicant in accordance with or have otherwise verified that this applicant complies with pertinent procedures, standards, policies, and or
necessary requirements with the result indicated below.
Approved -- Temporary Certificate Issued (Original Attached) Disapproved -- Disapproval Notice Issued (Original Attached)
Location of Test (Facility, City, State)
Duration of Test
Ground Simulator/FTD Flight
Certificate or Rating for Which Tested Type(s) of Aircraft Used Registration No.(s)
Student Pilot Certificate Issued
Examiner's Recommendation
Accepted Rejected
Reissue or Exchange of Pilot Certificate
Special Medical test conducted -- report forwarded
to Aeromedical Certification Branch, AAM-330
Certificate or Rating Based on
Military Competence
Foreign License
Approved Course Graduate
Other Approved FAA Qualification Criteria
Flight Instructor Ground Instructor
Renewal
Reinstatement
Instructor Renewal Based on
Activity Training Course
Test Duties and
Responsibilities
Training Course (FIRC) Name Graduation Certificate No. Date
Date Inspector's Signature (Print Name & Sign) Certificate No. FAA District Office
Attachments:
Student Pilot Certificate (Copy)
Knowledge Test Report
Temporary Airman Certificate
Notice of Disapproval
Superseded Airman Certificate
Airman's Identification (ID)
Form of ID
__________________________________________________
Number
__________________________________________________
Expiration Date
__________________________________________________
Telephone Number
__________________________________________________
ID:
Name: _____________________________________________
Date of Birth: _______________________________________
Certificate Number: __________________________________
E-Mail Address ______________________________________
FAA Form 8710-1 (4-00) Supersedes Previous Edition NSN: 0052-00-682-5007
Electronic Version (Adobe)
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Completed 21 February 2020

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