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 30 minutes to complete this form. 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, and its expiration date is August 31, 2019. 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, ASP-110. See attached Privacy Act Information and Pilot’s Bill of Rights Written Notification of Investigation Detach these supplemental information instruction parts before submitting the attached form. Instructions for completing this form (FAA 8710-1 form) are attached. 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 applicant’s social security number, telephone number, and e-mail address are optional. For faster processing, the FAA encourages applicants to apply online using the FAA Integrated Airman Certification and Rating Application (IACRA). IACRA is available at https://iacra.faa.gov. Tear off this cover before submitting form AIRMAN CERTIFICATE AND/OR RATING APPLICATION PRIVACY ACT STATEMENT: This statement is provided pursuant to 5 U.S.C. § 552(a): The authority for collecting this information is contained in 49 U.S.C. §§ 40113, 44702, 44703, 44709, 44710, 44711 (a)(2) and 14 CFR Part 61. The principal purpose for which the information 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 applicant's social security number which is optional. Failure to provide all required information will result in the FAA 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 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 certificate(s) and/or rating(s) held, limitations, date of issuance and certificate number; • The status of the airman’s certificate (i.e., whether it 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, 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 medical 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 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 pursuant 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 Carrier 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 individuals 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 secureenvironment. (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, the Department of Homeland Security (DHS), DOJ and other authorized Federal agencies, for their use in managing, tracking and reporting aviation-related securityevents. (n) Other possible routine uses published in the Federal Register (see Prefatory Statement of General Routine Uses for additional uses (65 FR 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 (TS A) 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. Your signature on this form (FAA Form 8710-1) acknowledges that you received the Pilot’s Bill of Rights Written Notification of Investigation at the time of this application. PILOT’S BILL OF RIGHTS WRITTEN NOTIFICATION OF INVESTIGATION The information you submit on the attached FAA Form 8710-1, Airman Certificate and/or Rating Application, will be used by the Administrator of the Federal Aviation Administration as part of the basis for issuing an airman certificate, rating, or inspection authorization to you under Title 49, United States Code (U.S.C.) section 44703(a), if the Administrator finds, after investigation, that you are qualified for, and physically able to perform the duties related to the certificate, rating, or inspection authorization for which you are applying. Therefore, in accordance with the Pilot’s Bill of Rights, the Administrator is providing you with this written notification of investigation of your qualifications for an airman certificate, rating, or inspection authorization: • The nature of the Administrator’s investigation, which is precipitated by your submission of this application, is to determine whether you meet the qualifications for the airman certificate, rating, or inspection authorization you are applying for under Title 14, Code of Federal Regulations (CFR) part 61. • Any response to an inquiry by a representative of the Administrator by you in connection with this investigation of your qualifications for an airman certificate, rating, or inspection authorization may be used as evidence against you. • A copy of your airman application file for this date is available to you upon your written request addressed to: Federal Aviation Administration Airmen Certification Branch, AFB-720 P.O. Box 25082 Oklahoma City, OK 73125-0082 (If you make a written request for your airman application file, please provide your full name, date of birth or airman certification number for identification purposes, and the date of application.) iii AIRMAN CERTIFICATE AND/OR RATING APPLICATION INSTRUCTIONS FOR COMPLETING FAA FORM 8710-1 I. APPLICATION INFORMATION. Mark “X” in all appropriate blocks(s). Note: Please enter all dates in eight digits as MM/DD/YYYY. Use numeric characters, (e.g. 01/01/2014). Block A. Name. Enter full legal name (Last, First, Middle). If your full legal name is more than 50 characters, 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 part 61.25. If you do not have a middle name, enter “NMN.” If you have a middle initial only, indicate “Initial only.” Indicate if you are a Jr., II, or III. Block B. Social Security Number. Enter either your 9-digit social security number, “Do Not Use” or “None” if you are not a U.S. citizen. If entering a social security number, only enter a 9-digit U.S. social security number (optional). See supplemental Privacy Act Information. Block C. Date of Birth. Enter your date of birth in the following format: MM/DD/YYYY. Check for accuracy. Verify 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 El. Residential Address. Enter your complete residential address. This must include street number, city, state, and zip code. If the applicant has a foreign address, the country must be stated. If a residential address does not exist, a map or written directions to the applicant’s physical residence must be attached to the application. Verify that the numbers are not transposed. Block E2. Mailing Address. Enter your mailing address, if different than block El. This may be a residence, post office box, rural route, flight school address, personal mail box (PMB), commercial address, or other mail drop location, as applicable. The address provided in block E2, if any, will be printed on the permanent airman certificate. If you want your airman certificate mailed to an address other than provided in blocks El or E2, you will need to provide instructions on a separate attachment or in the remarks section of the form. Block F. Citizenship/Nationality. Mark USA if you are a U.S. Citizen or legally naturalized U.S. Citizen. If you are not a U.S. citizen, mark “Other” and enter the country where you are a legal citizen. To claim Dual Citizenship the applicant must present appropriate documentation of citizenship for each country. Block G. Do you read, speak, write and understand the English language? Mark yes or no. If you answered “No” and it is due to medical reasons, an operating limitation will be placed on the airman certificate. 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 Color. Spell out the color of your hair. Choose from the following: bald, black, blond, brown, gray, red or white. If you wear a wig or toupee, enter the color of your hair under the wig or toupee. Block K. Eye Color. Spell out the color of your eyes. Choose from the following: black, blue, brown, gray, green, or hazel. Block L. Sex. Mark either Male or Female as appropriate. Block M. Do You Hold or Have You Ever Held An FAA Pilot Certificate? Mark yes or no. (NOTE: A student pilot certificate is a pilot certificate.) If. Yes, complete Blocks Ml, M2, and M3. Block Ml. Grade of Certificate. Enter the grade of the FAA pilot certificate you hold (i.e., Student, Recreational, Private, Commercial, or ATP). DO NOT enter flight instructor certificate information. Block M2. Certificate Number. Enter your current FAA certificate number as it appears on the pilot certificate. Block M3. Date Issued. Enter the date your pilot certificate was last issued. Block N. Do You Hold, or Have You Ever Held a Medical Certificate? Mark applicable boxes. If yes, complete blocks Nl, N2, and N3. Block Nl. Class of Medical Certificate. Enter the class as shown on the medical certificate, (i.e., First, Second, or Third Class). If your most recent medical certificate which was valid at some point after July 14 th , 2006 has expired and you are operating under BasicMed, enter “BASICMED” in this field. Block N2. Name of Medical Examiner. Enter the medical examiner’s name as shown on your medical certificate. If you are operating under BasicMed, leave blank. Block N3. Date Issued. Enter the date your medical certificate was issued. If you are operating under BasicMed, leave blank. Block O. Narcotics Drugs. Mark appropriate block. Only mark “Yes” if you have actually been convicted. If you have been charged with a violation which has not been adjudicated, mark “No.” Do not include alcohol offenses involving a motor vehicle mode of transportation as those are covered on the FAA Form 8500-8, Medical application. Block Ol. Date of Final Conviction. If block “N” was marked “Yes” provide 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 or represented. If a flight simulation training device (FSTD) is used, indicate Level of Device(s). 2. Total time in this aircraft and/or approved full flight simulator (FFS) or flight training device (FTD) (Hrs.) - (2a) Enter the total Flight Time (2b) Enter Pilot-In- Command (PIC) Flight Time. Block B. U.S. Military Competence Or Experience. Enter your branch of service, date rated as a U.S. military pilot, and your rank or grade. In block 4a and 4b, enter the make and model of each military manned aircraft used to qualify (as appropriate). ATD, FTD, or FFS time cannot be used. Block C. Graduate of an Approved Course. 1. Name, Location, Certification Number of Training Agency/Center, as shown on the graduation certificate. Indicate if this was a part 142 training center. 2. Curriculum From Which Graduated. Enter name of curriculum and level, category, and/or type rating, as applicable. 3. Date. Date of graduation from indicated course. Note: Approved course graduate must also complete block A “Completion of Test or Activity, ” if the course is not part of an Air Agency or a part 142 Training Center. Block D. Holder of Foreign License. 1. Country that Issued the Foreign Pilot License. 2. Grade Of Foreign Pilot License (i.e. private, commercial, etc). 3. Number. Number which appears on the foreign license. 4. Ratings. Enter the FAA equivalent only ratings that appear on the foreign license. Indicate the ratings as they will appear on the FAA Certificate (i.e. ASEL, AMEL, ROTORCRAFT HELICOPTER, CE-500,etc). Block E. Completion of Air Carrier’s Training Program. 1. Name of air carrier. 2. Date program was started. 3. Identify the training program accomplished. III. RECORD OF PILOT TIME. At a minimum , the applicant should complete the blocks applicable to the certificate or rating sought; however, it is recommended that all pilot time be entered. If decimal points are utilized, ensure that they are legible. Time entered in the “Class Totals” block should reflect time in aircraft class for the certificate or rating sought with this application. The time entered for an FFS, FTD, and/or ATD may be credited towards the total time in the category, class, and instrument time as permitted by the regulations. Add any Flight Engineer time used for ATP in remarks section. IV. HAVE YOU PREVIOUSLY RECEIVED A NOTICE OF DISAPPROVAL OR BEEN DENIED FOR ANY REASON FOR THE CERTIFICATE AND/OR RATING FOR WHICH YOU ARE APPLYING? Mark “Yes” or “No” as appropriate. V. APPLICANT’S CERTIFICATION. A. Signature. Sign your name. B. Date. The date you signed the application. FAA Form 8710-1 (10-17) Supersedes Previous Edition TYPE OR PRINT ALL ENTRIES IN INK Form approved OMB No: 2120-0021 08/31/2019 U.S. Department of Transportation Federal Aviation Administration Airman Certificate and/or Rating Application I. APPLICATION INFORMATION (Mark 'X' in all the blocks applicable to the certificate or rating for which you are applying): Certificates Ratings Other Information/Requests Pilot Instructor: □ student □ Recreational □ Flight □ Private □ Commercial □ Ground □ ATP-Restricted []ATP Category and/or Class: □ A5E []AME □ Land []Sea □ Helicopter □Balloon □Glider Gyroplane [^Airship □Powered-Lift Type Rating: QAdded Rating Instrument Ground Instructor: □ Airplane Q Basic □ Helicopter □Advanced □ Powered-Lift □instrument □ initial □Reexamination □instrument Proficiency Check □ Renewal □Reissuance □Medical Flightiest □ Reinstatement □FlightReview □Limitation Removal Specify other: □|lPL A. Name (Last First, Middle) B. SSN (US Only) C. Date of Birth MM/DD/YYYY D. Place Of Birth (City and State) or (City and Country) El. Residential Address (Including City, State, Zip Code, and Country) E2. Mailing Address (This address will be printed on the permanent airman certificate, if different than block El.) F. Citizenship/Nationality | |USA Pother specify: G. Do you read, speak, write, & understand the English language? □ Yes □ No H. Height 1. Weight J. HairColor K. Eye Color L. Sex (inches) (pounds) 0 Male r Female M. Do you hold, or have you ever held an FAA pilot certificate? □ Yes □ No Ml. Grade of Certificate M2, Certificate Number M3. Date Issued N. Do you hold, or have you ever held a Medical Certificate? Yes-FAA — Yes -Foreign □[ Yes-Military No Nl. Class of Certificate N2. Name of Medical Examiner N3. Date Issued 0. 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? Do not include alcohol offenses involving motor vehicle mode of transportation as those offenses are covered on the FAA Form 8500-8, Airman Medical Application Form. □ Yes □ No 01, Date of Final Conviction II. CERTIFICATE OR RATING APPLIED FOR ON BASIS OF: □ . Completion of ' Test or Activity 1. Aircraft to be used (Ifflighttestrequired) 2, Total time in this aircraft and/or approved FFS or FTD (hours): a. Flight Time b. As P ilot-in- Command _ U.S. Military □ B, Competence or Experience 1. U.S. Military Service 2. Date Rated in U.S. Military 3. RankorGrade 4. List Military aircraft for which you have: a. logged pilot time or provided flight instruction (IP) (make and model) b. passed an Instrument P roficiency C heck (PiiotorCFi) - (make and model) □ C, Graduate of an Approved Course l.Training Agency or Training Center: la. Name lb. Location (City and State) lc. Certification Number 2. Curriculum From Which Graduated (Level, Category, and Class and/orType Rating) Id. Part 142? Yes No 3. Date □ D. Holder of Foreign License 1. Country that Issued the Foreign Pilot License 2, Grade of Foreign Pilot License 3. Foreign PilotLicense Number 4. Ratings Held On Foreign Pilot License (FAA equivalentonly- e.g. ASEL, AMEL,Type rating, etc.) □ E- Air Carrier Training Program 1. Name of AirCarrier 2. Date Training Began 3. Accomplished Training P rogram Initial Upgrade Transition Recurrent . RECORD OF PILOT TIME (Do not write in the shaded areas) IV, Have you previously received a Notice of Disapproval or been denied for any reason for the certificate AND/OR rating for which you are applying? □ Yes | | No V, APPLICANT'S CERTIFICATION: icertify 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 received the Pilot's Bill of Rights Written Notification of Investigation that accompanies this form. I have also read and understand the Privacy Act statement that accompanies this form. Signature of Applicant Date MM/DD/YYYY FAA Form 8710-1 (10-17) Supersedes Previous Edition Page 1 of 2 Instructor Action i | Accepted Student Pilot Application -1 have personally reviewed the applicant's information and verified the person meets the eligibility requirements and verified applicants identification Q Rejected Student Pilot Application i | F light Review Q Instrument Proficiency Check Q Recommendation -1 have personally instructed ttie applicantand considerthis person ready to take the test Date Authorized Flight Instructor's Signature (Print Name and Sign) Flight Instructor Certificate Number Certificate Expiration Date Air Agency’s Recommendation The applicant has successfully completed our_course, and is recommended for certificate or rating without further practical test. Date Agency Name and Number Official Signature Designated Examiner or Airman Certification Representative Report [J Accepted Student Pilot Application Q Rejected Student Pilot Application j j I have personally reviewed this applicant's pilot logbook and/or training record, and I certify that the individual meets the applicable requirements of 14 CFR Part 61 for the certificate or rating sought j j I have personally reviewed this applicant's graduation certificate, and found it to be appropriate and in order, and have returned the certificate. (Original ATP CTP graduation certificate must be attached) [J I have personally tested and/or verified this applicant in accordance with pertinent procedures and standards with the result indicated below. [J I have personally delivered the Written Notification under the Pilots Bill of Rights to the applicant. Q Approved - Temporary Certificate Issued (Original Attached) Q Disapproved - Disapproval Notice Issued (Original Attached) Location of Test (Name of Facility or Airport City, State) __ Duration of Test _ Ground/Oral FFS /FTD Flight Certificate or Rating Being Applied For (Grade, Category, Class and/or Type Rating) Type(s) of Aircraft Used Registration Number(s) Date | Examiner's Signature (PrintName & Sign) Certificate Number Designation Number Designation Expires Evaluator’s Record (Use for All ATP Certificate(s) and/or Type Rating(s)) Inspector Examiner Signature and Certificate Number Date □ □ _ _ □ □ _ _ □ □ _ _ □ □ _ _ Ground/Oral Approved FFS/FTD Check Aircraft Flight Check Advanced Qualification Program