8710-6 Examiner Designation and Qualification Record

US Department
of Transportation
Federal Aviation
Administration

EXAMINER DESIGNATION AND QUALIFICATION RECORD
Privacy Act Statement: The information on this form is solicited under authority of the Federal Aviation Regulations
Part 183. The purpose of this information is to establish your qualifications as an examiner. Submission of the data is
mandatory. Incomplete submission may result in delay or denial of y our request. The data will be used to determine
your eligibility as an examiner, and for statistical purposes. In addition, the data also becomes part of the Privacy Act
system of records DOT/FAA 830, Representatives of the Administrator, and is subject to the additional conditions of
that published system.
Paperwork Reduction Act Statement: The information collected on this form is necessary to determine applicant
eligibility for Designated Pilot Examiner, Proficiency Pilot Examiner, and Airman Certification Representative. The
information is used to determine certification eligibility. We estimate that it will take 30 minutes to complete the form.
The information collection is required to obtain a benefit. The information collected becomes part of the Privacy Act
system of records DOT/FAA 830, Representatives of the Administrator. 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 2120-0033. 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, ABA 20.

TEAR OFF
BEFORE USE
FAA Form 8710-6

(10-83)

SUPPLEMENTAL
INFORMATION
Detach this part before using form below.

EXAMINER DESIGNATION
AND QUALIFICATION RECORD

US Department
of Transportation
Federal Aviation
Administration

Attach supplemental sheets if more space is required for any item.
1. NAME (Last, first, middle)

Telephone No.

2. ADDRESS (Number, street, city, state, and ZIP code)

TYPE OF DESIGNATION

Form Approved
OMB No. 2120-0033
11/30/2007
PRIVATE PILOT
COMMERCIAL PILOT EXAMINER
AIRLINE TRANSPORT PILOT EXAMINER
PROFICIENCY PILOT EXAMINER
FLIGHT ENGINEER EXAMINER
FLIGHT INSTRUCTOR EXAMINER
OTHER

3. DATE OF BIRTH (Month, day, and year) 4. U.S. CITIZEN
YES
NO
YES

5. DO YOU NOW HOLD, OR HAVE YOU
EVER HELD, AN EXAMINER DESIGNATION

TYPE AND NUMBER

NO

6. HAS ANY CERTIFICATE OR RATING ISSUED YOU EVER BEEN SUSPENDED OR REVOKED OR HAVE YOU PAID A CIVIL PENALTY AS A RESULT OF A VIOLATION
OF THE FEDERAL AVIATION REGULATIONS. (Complete for original designations only.)
YES
NO
7. CERTIFICATES HELD
TYPE

CERTIFICATE NO.

RATINGS

DATE ISSUED

8. FLIGHT EXPERIENCE (in hours)
AIRPLANE
TOTAL

ROTORCRAFT

LAST 12 MOS.

TOTAL

LAST 12 MOS.

GLIDERS
TOTAL

LAST 12 MOS.

INSTRUMENT
FLIGHT
(Actual or sim)

NIGHT
FLIGHT

PILOT-IN-COMMAND
FLIGHT INSTRUCTION
GIVEN
COPILOT
FLIGHT NAVIGATOR
FLIGHT ENGINEER
9. EMPLOYMENT (Indicate professional experience pertinent to this designation)
EMPLOYER'S NAME

NATURE OF WORK

DATES

TITLE OF POSITION

10. SPECIAL TRAINING PERTINENT TO THE DESIGNATION

CERTIFICATION: I certify that I am familiar with the requirements for this designation, its privileges and limitations, and that the information stated herein is true. It is
understood that this designation may be terminated upon notice by the FAA for the reasons specified in section 183.15(c) of the Federal Aviation Regulations.
DATE

FAA Form 8710-6 (10-83)

SIGNATURE

FOR FAA USE
TYPE OF ACTION

DATE LAST REPORT
SUBMITTED

FLIGHT TEST ACTIVITIES-GENERAL AVIATION
(Complete for renewals and additional designations)

ORIGINAL ISSUANCE

TOTAL
DISAPPROVED
SUBMITTED BY EXAMINER

CERTIFICATES/RATINGS
RENEWAL

ACCEPTED
BY
INSPECTOR

RECHECKED
BY
INSPECTOR

NO. RETURNED FOR
CORRECTION

PRIVATE PILOT
COMMERCIAL PILOT

ADDITIONAL AUTHORITY

AIRLINE TRANSPORT PILOT
INSTRUMENT RATING

SPOT CHECK ONLY NO RENEWAL EFFECTED

PRIVATE

ADDITIONAL
RATINGS

REINSTATEMENT

COMMERCIAL
ATR

Complete for original issuance and
reinstatements only

CHARACTER AND REPUTATION (Include industry and community reputation as well as personal knowledge possessed by FAA personnel)

PROFESSIONAL ABILITY (Brief narrative description of examiner indoctrination and training given and results expressed as "good," "excellent," or "unsatisfactory.")

APPROVE

INSPECTOR'S RECOMMENDATION/ACTION

DISAPPROVE

JUSTIFICATION FOR APPROVAL/REASONS FOR DISAPPROVAL

The individual named has been flight tested/examined and deemed competent to perform the duties of the designation indicated below.

DESIGNATION

PRIVATE PILOT

CATEGORY

COMMERCIAL PILOT EXAMINER
AIRLINE TRANSPORT PILOT EXAMINER
PROFICIENCY PILOT EXAMINER
FLIGHT ENGINEER EXAMINER
FLIGHT INSTRUCTOR EXAMINER
OTHER

DATE

ADDITIONAL QUALIFICATIONS LIMITATIONS (For pilot flight engineer
examiner give aircraft category)

AIRPLANE
ROTOCRAFT
GLIDER
OFFICE NO.

INSPECTOR'S SIGNATURE

REGIONAL OFFICE ACTION
CONCUR

DATE

SIGNATURE

DISAPPROVE
CERTIFICATE OF AUTHORITY ISSUED

TYPE OF DESIGNATION
NO.

DO TO SERVE UNDER

EXPIRATION DATE