8710-10 National Examiner Board-Designated Pilot Examiner Candid

Form Approved OMB No. 2120-0033
11/30/2007
NATIONAL EXAMINER BOARD-DESIGNATED PILOT EXAMINER CANDIDATE APPLICATION
Supplemental information and Instructions
U.S. Department of Transportation
Federal Aviation Administration
Privacy Act Statement
We collect the information on this form under the authority of Title 14 CFR Part 183. The purpose of this information is to evaluate your application and
establish your qualifications as a general aviation designated pilot examiner (DPE). Submission of the data is mandatory except for your Social Security
Number, which is voluntary. Incomplete submission may result in delay or denial of your request. The data will be used to determine your eligibility to
become a general aviation designated pilot examiner, and will become part of the Privacy Act system of records DOT/FAA 830, Representatives of the
Administrator. As part of that system of records, the information will be subject to the following routine uses as published in the Federal Register: (1) To
facilitate written and oral communication between the FAA and it's representatives; and (2) To Provide the public with the names and addresses of
certain categories of representatives who may provide service to them. Providing your Social Security Number is voluntary. If provided, it will be used
for record keeping purposes and to help prevent your records from being confused with another person of the same name.
Paperwork Reduction Act Statement
We use this form to collect essential information concerning your professional and personal qualifications to become a designee. The FAA uses this information to
screen and select the designee. We estimate that it will take about 54 minutes to complete the form. Providing the information is mandatory is you wish to
apply to become a Designated Pilot Examiner. The information becomes part of the Privacy Act system of records DOT/FAA 830, Representatives of the Administrator,
and is subject to the routine uses of that system as described above. Please not that an Agency may not conduct or sponsor, and a person is not required to respond
to, a collection of information unless it display a currently valid OMB control number. The OMB control number associated with this collection of information 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.
Detach all supplemental Information and Instruction shoots before submitting application.

NATIONAL EXAMINER BOARD-DESIGNATED PILOT EXAMINER CANDIDATE APPLICATION
HOW TO APPLY -- (Initial Designations)
Answer all applicable questions (blocks) fully.
Refer to the attached instruction sheets if you require assistance to answer a question (block).
Complete, sign, and date this application in black ink.
If you need more space to answer a question (block), use additional sheets of blank paper. Be sure to indicate the question (block) number and
your name at the top of each additional sheet.
Attach a copy (front and back) of all applicable pilot, flight instructor, and airman medical certificates to this application.
Remove all instruction sheets before you send in your completed application.
Be sure to keep a completed copy of the application and all additional sheets for your files.
WHERE TO SEND APPLICATION-­
Federal Aviation Administration, Designee Standardization Branch (AFS-640), ATTN: National Examiner Board, P.O. Box 25082,
Oklahoma City, OK 73125-0082
WHAT HAPPENS TO YOUR APPLICATION-­
The National Examiner Board (NEB) will evaluate your application to ensure that you meet the selection criteria for the designation(s)
sought. The NEB will advise you, in writing, whether or not you meet the applicable selection criteria. If the NEB sends you a letter
stating you do not meet the selection criteria, do NOT take the predesignation knowledge test.
If the NEB sends you a letter stating you do meet the selection criteria, you will be directed to take the examiner predesignation knowledge test
appropriate to the designation(s) sought. For example: airplane (PEA), rotorcraft (PER), glider (PEG), and balloon (PEB). You may take the
examiner predesignation knowledge test at any FAA-approved computerized testing center. Request the pilot examiner predesignation knowledge
test for the category applicable to the designation(s) sought. You MUST forward the original test results to the NEB within 10 days of the date you
take the examiner predesignation knowledge test. Keep a copy of the test results for your personal records.
Upon receiving your original test results with a score of 80 percent or higher, the NEB will notify you of approval or disapproval for assignment to
the national examiner candidate pool. The NEB will forward only die top three ranking candidates within the national examiner candidate pool to
each FSDO that requests a new designee. If you are selected, you must be available to serve the entire FSDO area. The NEB keeps your application
in the national examiner candidate pool for 2 years or until a FSDO selects you, whichever comes first.
After 2 years, the NEB win delete the applications of all candidates not selected by a FSDO from the national examiner candidate pool. An
applicant must repeat the application process in order to apply for reassignment to the national examiner candidate pool.
NOTE: FAA Form 87 1 0- I 0 is used by the National Examiner Board for initial designation. FAA Form 87 1 0- I 0 does not supersede FAA
Form 8710-6, Examiner Designation and Qualification Record. FAA Form 8710-6 may still be used for renewal of PPE's, ACR's, and DPE's.
Request for reinstatement must go to the NEB if the applicant has moved from the original designating district office's area of responsibility.

FAA Form 8710- 10 (1 -00)

i

NSN: 0052-00-918-0000

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Form Approved OMB No. 2120-0033
11/30/2007
NATIONAL EXAMINER BOARD—
—DESIGNATED PILOT EXAMINER CANDIDATE APPLICATION
Supplemental Information and Instructions (Continued)
TYPES OF DESIGNATIONS AND DESIGNEE DEFINITIONS—
—
PE
- Private Pilot Examiner
CIRE
- Commercial and Instrument Rating Pilot Examiner
- Commercial Pilot Examiner (For rotorcraft, gliders, and/or lighter-than-air aircraft only.)
CE
ATPE - Airline Transport Pilot Examiner
GENERAL QUALIFICATIONS—
—
• The applicant must hold all pertinent category, class, and type ratings for each aircraft for which designation is sought.
• For a designation requiring a medical certificate, the applicant must hold a valid third-class airman medical certificate for initial designation. (A
medical certificate is NOT required for designations limited to examining in balloons and gliders.)
• The applicant must be at least 21 years old.
• The applicant must have a good record as a pilot and flight instructor with regard to accidents, incidents, and violations.
• The applicant must meet all eligibility and experience requirements for the specific designation sought in accordance with the tables beginning on
page iv for PE, CE, CIRE, ATPE requirements, the appropriate FAA order, handbooks, and pertinent, current Flight Standards Handbook Bulletin
for General Aviation.
• The applicant must have a reputation for integrity and dependability in the industry and the community.
• The applicant must have a history of a harmonious relationship with the FAA.
INSTRUCTIONS FOR COMPLETING FAA FORM 8710-10—
—
1. All entries on FAA Form 8710-10 must be made in black ink or typewritten.
2. Read the attached "Privacy Act Statement."
3. Complete blocks 1 through 33:
a. Block 1. Name (Last, First, Middle)—
(1) Enter your legal name. For record purposes, do not use more than one middle name.
(2) If you do not have a middle name, enter "NMN" (no middle name) or "NMI" (no middle initial).
(3) If you have initial(s) only, enter the initials and then enter "INITIALS ONLY."
(4) If you are a junior, III, IV, etc., so indicate.
b. Block 2. Social Security Number—
(1) Completing Block 2 is optional (see "Privacy Act Statement").
(2) Enter your Social Security Number or one of the following: "DO NOT USE" or "NONE."
c. Block 2A. Date of Birth—Enter date using eight-digit, numeric characters (e.g., 08/09/1960 not August 9, 1960).
d. Block 3. Permanent Mailing Address—Enter all required information, to include number and street, P.O. Box, City, State, and Zip Code.
e. Block 4. Telephone Number—Enter your home and business telephone numbers including the area code and extensions, if applicable.
You may also enter your Fax number, if applicable.
f. Block 5. This application is for:—Initial Application for NEB, Renewal Application for NEB, or Reinstatement (other than initial
designating FSDO) for NEB. Check the box to the left of the reason for this application. NOTE: Reinstatements are NOT to be sent
to the NEB unless the applicant has moved to a different district.
g. Block 6. Have you ever held an FAA pilot examiner designation in any region?—(If "YES," enter the date(s) and the supervising FSDO.)
h. Block 7. Type of designation(s) sought:—Check the box to the left of the designation(s) sought. Private Pilot Examiner (PE),
Commercial Pilot Examiner (CE), Airline Transport Pilot Examiner (ATPE), and Commercial Instrument Rating Examiner (CIRE). (See
the SPECIFIC ELIGIBILITY REQUIREMENTS criteria shown on pages iv and v.)
i.
Block 8. Enter the categories, classes, and types of aircraft for which authorization is sought.—Self-explanatory.
j.
Block 9. Enter the FSDO that has jurisdiction in the area where you desire to serve.—Self-explanatory.
k. Block 10. Enter the names of other FSDO's in whose areas you can provide examiner service on a regular basis, if any.—Self­

explanatory.

l.
Block 11. Has any certificate or rating issued to you ever been revoked?—(If "YES," describe the circumstances.)
m. Block 12. Have you had any aircraft accidents or incidents within the past 5 years?—(If "YES," describe the circumstances.)
n. Block 13. Are you a U.S. citizen?—(You must enter "YES" or "NO.") NOTE: You are not required to be a U.S. citizen in order to be a
designated examiner.
o. Block 14. If you are NOT a U.S. citizen, enter the country in which you hold citizenship. If you hold dual citizenship, indicate the
names of both countries.—Self-explanatory.
p. Block 15. Do you read, write, speak, and understand English fluently?—Self-explanatory.
q. Block 16. FAA certificates held—Enter all certificates held, their certificate numbers, and their ratings and limitations as shown on the
certificate. NOTE: You must provide copies (front and back) of all certificates.
r. Block 17. Enter all of your special training which is pertinent to the designation sought.—Self-explanatory.
s. Block 18A. Have you ever served as a chief or assistant chief instructor in a school authorized under Title 14 of the Code of Federal
Regulations (14 CFR) part 141?—(If "YES," enter the date(s).)
t.
Block 18B. Have you ever served as a check airman authorized under Title 14 of the Code of Federal Regulations (14 CFR) part 121
and/or part 135?—(If "YES," enter the date(s) and the FSDO.)

FAA Form 8710-10 (1-00)

ii

NSN: 0052-00-918-0000

Form Approved OMB No. 2120-0033
11/30/2007
NATIONAL EXAMINER BOARD—DESIGNATED PILOT EXAMINER CANDIDATE APPLICATION
Supplemental Information and Instructions (Continued)
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Block 18C. Have you ever been an FAA Aviation Safety Inspector?—(If "YES," enter the date(s) and the FSDO.)
Block 19. Have you ever been a military pilot evaluator?—(If "YES," enter the date(s).)
Block 20. Have you ever been an FAA Accident Prevention Counselor or FAA Aviation Safety Counselor?—(If "YES," enter the date(s)
and the FSDO.)
Block 21. Flight Experience—Enter all your actual flight time (in hours), as requested. Do not round off or approximate your hours (i.e.,
±). Do not write in the shaded areas. Answer Blocks 21A through 21I, if applicable. NOTE: Total flight instruction given and/or
instrument flight instruction given. (See the SPECIFIC ELIGIBILITY REQUIREMENTS criteria shown on pages iv and v.)
Block 22. Work Experience—Describe your current or most recent work experience in Block 22A and work backwards. Use a separate
block for each position described (e.g., Block 22A, Block 22B, etc.). Describe all of your work experience in specific detail that pertains
to your qualifications for the designation(s) sought. Describe each applicable position you held during at least the past 5 years. You
may describe work experience accrued more than 5 years ago. Include military service if your military experience is pertinent to your
application for an examiner designation.
(1) Complete the name, address, and telephone number of the employer/organization.
(2) Job Title: Self-explanatory.
(3) Dates Employed: Enter the dates of employment.
(4) Supervisor's Name: Self-explanatory.
(5) Reason for Leaving: Self-explanatory.
(6) Description of Duties: Enter a complete description of the duties performed during this period of employment.
Block 23. Briefly summarize your aviation activities and professional responsibilities that best qualify you to be a designated pilot
examiner.—Self-explanatory.
Block 24. During the past 5 years, were you fired from any job for any reason?—NOTE: If you answer "YES," you MUST enter the full
details in Block 31.
Block 25. Have you ever been convicted of any felony violation?—NOTE: If you answer "YES," you MUST enter the full details in
Block 31.
Block 26. Are you now under charges for any violation of law?—NOTE: If you answer "YES," you MUST enter the full details in
Block 31.
Block 27. Have you ever been imprisoned, been on probation, or been on parole?—NOTE: If you answer "YES," you MUST enter the
full details in Block 31.
Block 28. Have you ever been convicted by a military court-martial?—NOTE: If you answer "YES," you MUST enter the full details in
Block 31.
Block 29. Have you ever been discharged from a military service under a General discharge?—NOTE: If you answer "YES," you
MUST enter the full details in Block 31.
Block 30. Have you ever been discharged from a military service under other than honorable conditions?—NOTE: If you answer
"YES," you MUST enter the full details in Block 31.
Block 31. If you answered "YES" to any questions in Blocks 24 through 30, you MUST enter the full details.
Block 32. Education and Training—Are you a high school graduate? (If "YES," enter the name of the high school and the date you
graduated.) Are you a GED graduate? (If "YES," enter the date you received the GED.)
(1) College and/or Technical Training Dates: Enter the beginning and ending dates of the training that you attended.
(2) Name of School: Enter the name of the school(s) you attended.
(3) Curriculum or Study Program: Enter the curriculum or study program for each school(s) listed.
(4) Degree or Certificate Received: Enter degrees or certificates you received from each school(s) listed.
Block 33. Applicant's Signature—After you read the "RELEASE OF INFORMATION AND CERTIFICATION STATEMENT"
and the "NOTICE," sign the application, in black ink. After you sign your name, print or type your name under your signature. Enter
the date you signed the application using eight-digit, numeric characters (e.g., 08/09/1999 not August 9, 1999).

FAA Form 8710-10 (1-00)

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NSN: 0052-00-918-0000

Form Approved OMB No. 2120-0033
11/30/2007
NATIONAL EXAMINER BOARD—DESIGNATED PILOT EXAMINER CANDIDATE APPLICATION
Supplemental Information and Instructions (Continued)

LIST OF FLIGHT STANDARDS DISTRICT OFFICES
ALASKAN REGION (AAL)
ANC FSDO-03
ANCHORAGE, AK
FAI FSDO-01
FAIRBANKS, AK
JNU FSDO-05
JUNEAU, AK
CENTRAL REGION (ACE)
DSM FSDO-01
DES MOINES, IA
ICT FSDO-07
WICHITA, KS
LNK FSDO-09
LINCOLN, NE
MCI FSDO-05
KANSAS CITY, MO
STL FSDO-03
ST. ANN/
ST. LOUIS, MO
EASTERN REGION (AEA)
ABE FSDO-05
ALLENTOWN, PA
FRG FSDO-11
FARMINGDALE,
NY
AGC FSDO-03
W. MIFFLIN/
PITTSBURGH, PA
ALB FSDO-01
ALBANY, NY
BAL FSDO-07
BALTIMORE, MD
CRW FSDO-09
CHARLESTON, WV
DCA FSDO-27
CHANTILLY, VA
WASH, DC
HAR FSDO-13
NEW
CUMBERLAND/
HARRISBURG, PA
PHL FSDO-17
PHILADELPHIA,PA
NYC FSDO-15
GARDEN CITY, NY
PIT FSDO-19
CORAOPOLIS/
PITTSBURGH, PA
RIC FSDO-21
SANDSTON/
RICHMOND, VA
ROC FSDO-23
ROCHESTER, NY
TEB FSDO-25
TETERBORO, NJ
NY IFO-29
JAMAICA, NY

GREAT LAKES REGION (AGL)
CLE FSDO-25
CLEVELAND, OH
CMH FSDO-07
COLUMBUS, OH
CVG FSDO-05
CINCINNATI, OH
DPA FSDO-03
WEST CHICAGO,
IL
DTW FSDO-23
BELLEVILLE, MI
FAR FSDO-21
FARGO, ND
GRR FSDO-09
GRAND RAPIDS,
MI
IND FSDO-11
INDIANAPOLIS, IN
MKE FSDO-13
MILWAUKEE, WI
MSP FSDO-15
MINNEAPOLIS,
MN
ORD FSDO-31
SCHILLER PARK,
IL
RAPID CITY, SD
RAP FSDO-27
SBN FSDO-17
SOUTH BEND, IN
SPI FSDO-19
SPRINGFIELD, IL
NEW ENGLAND REGION (ANE)
BED FSDO-01
BEDFORD, MA
BDL FSDO-03
WINDSOR LOCKS,
CT
BOS FSDO-02
BOSTON, MA
PWM FSDO-05
PORTLAND, ME
NORTHWEST MOUNTAIN
REGION (ANM)
BOI FSDO-11
BOISE, ID
CPR FSDO-04
CASPER, WY
DEN FSDO-03
DENVER, CO
GEG FSDO-13
SPOKANE, WA
HLN FSDO-05
HELENA, MT
PDX FSDO-09
HILLSBORO/
PORTLAND, OR
SEA FSDO-01
SEATTLE, WA
SLC FSDO-07
SALT LAKE CITY,
UT
DEN FSDO-30
DENVER, CO

SOUTHERN REGION (ASO)
ATL FSDO-11
COLLEGE PARK/
ATLANTA, GA
BHM FSDO-09
BIRMINGHAM, AL
BNA FSDO-03
NASHVILLE, TN
CAE FSDO-13
WEST COLUMBIA, SC
FLL FSDO-17
FT. LAUDERDALE, FL
TPA-FSDO-35
TAMPA, FL
INT FSDO-05
WINSTON-SALEM, NC
JAN FSDO-07
JACKSON, MS
LOU FSDO-01
LOUISVILLE, KY
MEM FSDO-25
MEMPHIS, TN
MIA FSDO-19
MIAMI, FL
ORL FSDO-15
ORLANDO, FL
CHARLOTTE, NC
CLT FSDO-33
SAN JUAN, PR
SJU FSDO-21
TAMPA, FL
TPA FSDO
SOUTHWEST REGION (ASW)
ABQ FSDO-01
ALBUQUERQUE, NM
BTR FSDO-03
BATON ROUGE, LA
DAL FSDO-05
DALLAS, TX
DFW FSDO-07
DALLAS, TX
FTW FSDO-19
FT. WORTH, TX
HOU FSDO-09
HOUSTON, TX
LBB FSDO-13
LUBBOCK, TX
LIT FSDO-11
LITTLE ROCK, AR
OKC FSDO-15
OKLA. CITY, OK
SAT FSDO-17
SAN ANTONIO, TX

WESTERN PACIFIC REGION (AWP)
FAT FSDO-17
FRESNO, CA
HNL FSDO-13
HONOLULU, HI
LAS FSDO-19
LAS VEGAS, NV
LAX FSDO-23
LOS ANGELES, CA
LGB FSDO-05
LONG BEACH, CA
OAK FSDO-27
OAKLAND, CA
RAL FSDO-21
RIVERSIDE, CA
RNO FSDO-11
RENO, NV
SAC FSDO-25
SACRAMENTO, CA
SAN FSDO-09
SAN DIEGO, CA
SDL FSDO-07
SCOTTSDALE, AZ
SJC FSDO-15
SAN JOSE, CA
VNY FSDO-01
VAN NUYS, CA
SFO FSDO-03
SAN FRANCISCO,
CA
INTERNATIONAL FIELD OFFICE
LIST
FRA IFO-EA33
FRANKFURT
SIN IFO-WP33
SINGAPORE
BRX IFO-EA31
BRUSSELS
LGW IFO-EA35
LONDON
MIA IFO-SO23
MIAMI SPNGS, FL
DFW IFO-SW23
DALLAS, TX

SPECIFIC ELIGIBILITY REQUIREMENTS FOR
PRIVATE PILOT EXAMINER (PE) DESIGNEES
ELIGIBILITY
REQUIREMENTS
CERTIFICATES
REQUIRED
CERTIFICATE
CATEGORIES
RATINGS

HOURS AS PIC

HOURS AS FLIGHT
INSTRUCTOR (as a CFI
or as a Military Flight
Instructor)

AIRPLANE
Commercial Pilot
Flight Instructor
Both with Airplane
category
Both with appropriate
airplane class rating(s)
Instrument-Airplane on
pilot certificate only
2,000
• 1,000 in airplanes that
include 300 in past
year
• 300 in airplane class
• 100 at night
500 in airplanes
• 100 in class

FAA Form 8710-10 (1-00)

ROTORCRAFT
Commercial Pilot
Flight Instructor
Both with Rotorcraft category

GLIDERS
Commercial Pilot
Flight Instructor
Both with Glider
category

Helicopter or Gyroplane class
rating(s), as appropriate

1,000
• 500 in rotorcraft that
include at least 100
in past year
• 250 in helicopters or 150 in
gyroplanes, as appropriate
200 in helicopters or
gyroplanes, as appropriate

iv

500
• 200 in gliders
that include 10
hours in past
year of at least
10 flights
100 in gliders

L-T-A AIRSHIPS
Commercial Pilot

L-T-A BALLOON
Commercial Pilot

Lighter Than Air

Lighter Than Air

Airship class rating

Balloon class rating

1,000
• 500 in airships that
include at least 200 in
past year
• 50 at night

200
• 100 in balloons that
include 20 hours in past
year of at least 10 flights
each of at least 30
minutes duration
50 in balloons
• 10 in past year

100 in airships

NSN: 0052-00-918-0000

Form Approved OMB No. 2120-0033
11/30/2007
NATIONAL EXAMINER BOARD—DESIGNATED PILOT EXAMINER CANDIDATE APPLICATION
Supplemental Information and Instructions (Continued)
SPECIFIC ELIGIBILITY REQUIREMENTS FOR
COMMERCIAL PILOT EXAMINER (CE) DESIGNEES
ELIGIBILITY
REQUIREMENTS
CERTIFICATES REQUIRED

AIRPLANE

CERTIFICATE
CATEGORIES
RATINGS

ROTORCRAFT
(VFR ONLY)
Commercial Pilot Flight
Instructor
Both with Rotorcraft category
Helicopter or Gyroplane class
rating(s), as appropriate
2,000
• 500 in rotorcraft that
include at least 100 in past
year
• 250 in helicopters or 150 in
gyroplanes, as appropriate.
• If applicable, 100 in large
helicopters that include 50 in
the type helicopter sought,
and 25 in each additional
type sought
200 in helicopters or
gyroplanes, as appropriate.
• 50 in helicopters or
gyroplanes, as appropriate,
preparing pilots for a
Commercial Pilot Certificate

HOURS AS PIC

HOURS AS FLIGHT
INSTRUCTOR (as a CFI or
as a Military Flight Instructor)

GLIDERS
Commercial Pilot
Flight Instructor
Both with Glider
category

L-T-A AIRSHIPS
Commercial Pilot

L-T-A BALLOON
Commercial Pilot

Lighter-Than-Air

Lighter-Than-Air

Airship class rating

Balloon class rating

500
• 250 in gliders that
include at least 20
hours in the past
year of at least 50
flights

2,000
• 500 in airships that
include at least 200
in past year
• 50 at night

200
• 100 in gliders

100 in airships

200
• 100 in balloons that
include at least 20
hours in past year of
at least 10 flights
each of at least 30
minutes duration
• Held a Commercial
Pilot CertificateBalloon for at least 1
year
50 in balloons
• 10 in the past year

SPECIFIC ELIGIBILITY REQUIREMENTS FOR
COMMERCIAL AND INSTRUMENT RATING EXAMINER (CIRE) AND
AIRLINE TRANSPORT PILOT EXAMINER (ATPE) DESIGNEES
ELIGIBILITY
REQUIREMENTS

TYPE OF CIRE DESIGNATION
AIRPLANE &
INSTRUMENT

CERTIFICATES
REQUIRED
CERTIFICATE
CATEGORIES
RATINGS

Commercial Pilot Flight
Instructor
Both with Airplane
category
Both with appropriate
airplane class ratings and
Instrument-Airplane

HOURS AS PIC

2,000
• 1,000 in airplanes that
include 300 in airplanes in
past year
• 500 in class of airplane
• 100 at night in airplanes
• 200 in complex airplanes
• 100 instrument flight
(actual or simulated)
• If applicable, 300 in large
or turbine-power airplanes,
that include 50 in type
sought and 25 in each
additional type sought
500 in airplanes
• 100 in class of airplane
• 250 instrument flight
instructor time, that
includes 200 in airplanes

HOURS AS FLIGHT
INSTRUCTOR (as a CFI
or as a Military Flight
Instructor)

FAA Form 8710-10 (1-00)

HELICOPTER &
INSTRUMENT

TYPE OF ATPE DESIGNATION
AIRPLANE
HELICOPTER

Commercial Pilot Flight
Instructor
Both with Rotorcraft category

Airline Transport Pilot
Flight Instructor
Both with Airplane category

Airline Transport Pilot
Flight Instructor
Both with Rotorcraft category

Helicopter class rating;
Instrument-Helicopter

Both with appropriate
airplane class rating(s) and
instrument privileges on
ATP and InstrumentAirplane on CFI
2,000
• 1,500 in airplanes, that
include 300 in airplanes in
past year
• 500 in class airplane
• 100 at night in airplanes
• 200 complex airplanes
• 100 instrument flight
(actual or simulated)
• If applicable, 300 in large
or turbine-power airplanes,
that include 50 in type
sought and 25 in each
additional type sought
500 in airplanes
• 100 in class of airplane
• 250 instrument flight
instructor time, that include
200 in airplanes
• 150 preparing pilots for
Commercial Pilot or ATP
with airplane category or
type rating or InstrumentAirplane rating

Both with Helicopter rating and
instrument privileges on ATP and
Instrument-Helicopter on CFI

2,000
• 500 in helicopters that include
100 in helicopters in past year
• 100 instrument flight (actual
or simulated)
• If applicable, 100 in large
helicopters, that include 50 in
type sought and 25 in each
additional type sought

250 in helicopters
• 50 instrument flight
instruction in helicopters
• 100 preparing pilots for
Commercial Pilot-Helicopter

v

2,000
• 1200 in helicopters, that include 100
in helicopters in past year
• 100 instrument flight (actual or
simulated)
• If applicable, 100 in large
helicopters, that include 50 in type
sought and 25 in each additional type
sought

250 in helicopters
• 50 of instrument flight instruction in
helicopters
• 100 in helicopters preparing pilots
for Commercial Pilot Certificate or
ATP Certificate with a Helicopter
class or type rating or InstrumentHelicopter rating

NSN: 0052-00-918-0000

FormApprovedOMBNo.2120-0033

11/30/2007

NATIONAL EXAMINER BOARD—DESIGNATED PILOT EXAMINER CANDIDATE APPLICATION
U.S. Department of Transportation
Federal Aviation Administration
1. Name (Last, First, Middle)—

2. Social Security Number—
-

3. Permanent Mailing Address—
City:

State:

5. This application is for:—

�
�
�

Initial Application for NEB
Renewal Application for NEB
Reinstatement (other than initial
designating FSDO) for NEB

2A. Date of Birth—

4. Telephone Numbers—
Home Phone: (
)
Zip Code:
Business Phone: (
)
Fax Number: (
)
6. Have you ever held an FAA pilot examiner
7. Type of designation(s) sought:—
designation in any region?—
(If "Yes," enter the date(s) and the supervising
� PE
FSDO.)
� CE
� YES
� NO
� ATPE
From (mo/yr):____________
� CIRE
To (mo/yr):______________
FSDO:__________________

8. Enter the categories, classes, and types of
aircraft for which authorization is sought.—
_____________________________________

9. Enter the FSDO that has jurisdiction in the
area where you desire to serve.—
____________________________________

10. Enter the names of other FSDO's in whose areas you can
provide examiner service on a regular basis, if any.—
______________________________________________

_____________________________________

____________________________________

______________________________________________

_____________________________________

____________________________________

______________________________________________

_____________________________________

____________________________________

______________________________________________

11. Has any certificate or rating issued to you ever been revoked?—
(If "YES," describe the circumstances.)

12. Have you had any aircraft accidents or incidents within the past 5 years?—
(If "YES," describe the circumstances.)

� YES
� NO
__________________________________________________________

� YES
� NO
_______________________________________________________________

__________________________________________________________

_______________________________________________________________

__________________________________________________________

_______________________________________________________________

__________________________________________________________

_______________________________________________________________

__________________________________________________________

_______________________________________________________________

13. Are you a U.S. citizen?—

� YES

� NO

14. If you are NOT a U.S. citizen, enter the
country in which you hold citizenship. If you
hold dual citizenship, indicate the names of
both countries.—
____________________________________

15. Do you read, write, speak, and understand English
fluently?—

� YES

� NO

16. FAA certificates held—You MUST provide copies (front and back) of all certificates.
Type of Certificate
Certificate Number
_______________________________________ ______________________________________

Ratings and Limitations (as shown on the certificate)
_________________________________________________

_______________________________________

______________________________________

_________________________________________________

_______________________________________

______________________________________

_________________________________________________

17. Enter all of your special training which is pertinent to the designation sought.—
__________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________

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18A. Have you ever served as a chief or assistant chief instructor in a school authorized under Title 14 of the Code of Federal Regulations (14 CFR) part 141?—
(If "YES," enter the date(s).)

� YES

� NO

From (mo/yr):_____________ To (mo/yr):_____________

18B. Have you ever served as a check airman authorized under Title 14 of the Code of Federal Regulations (14 CFR) part 121 and/or part 135?—
(If "YES," enter the date(s) and the FSDO.)

� YES

� NO

From (mo/yr):_____________ To (mo/yr):_____________

FSDO:____________________________________

18C. Have you ever been an FAA Aviation Safety Inspector?—(If "YES," enter the date(s) and the FSDO.)

� YES

� NO

From (mo/yr):_____________ To (mo/yr):_____________FSDO:_________________________________________

19. Have you ever been a military pilot evaluator?—(If "YES," enter the date(s).)

� YES

� NO

From (mo/yr):_____________ To (mo/yr):_____________

20. Have you been an FAA Accident Prevention Counselor or FAA Aviation Safety Counselor?—(If "YES," enter the date(s) and the FSDO.)

� YES

�

NO

From (mo/yr):_____________To (mo/yr):_______________FSDO:___________________________________________

21. Flight Experience—Enter all your actual flight time (in hours), as requested. Do not round off or approximate your hours
(i.e., ±). Do not write in the shaded areas. Answer Blocks 21A through 21I, if applicable. NOTE: Total flight instruction
given and/or instrument flight instruction given. (See the SPECIFIC ELIGIBILITY REQUIREMENTS

21A. Enter turbine-powered large
airplanes and or large
helicopters.—

criteria shown on pages iv and v.)

Aircraft Class/
Experience

PIC
Total

PIC
Last
12 Mos.

Total (NonInstrument)
Flight
Instruction
Given (Civilian/
Military)

Instrument Flight
Instruction Given

PIC
Night

Instrument Flight
(Actual/
Simulated)

ASEL

/

/

AMEL

/

/

ASES

/

/

AMES

/

/

Helicopter

/

/

Flight
Instruction
Given
(Balloons Last
12 Mos.)

Aircraft Make and Model

PIC
Total

Gyroplane

Glider

Airship

Balloon

21B. Enter number of glider flights as PIC within the past year.—______________________________________________________________________________

21C. Enter number of balloon flights as PIC that were at least 30 minutes duration within the past year.—______________________________________________

FAA Form 8710-10 (1-00)

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21D. Enter number of hours as PIC in complex airplanes.—___________________________________________________________________________________

21E. Enter number of hours flight instruction given in rotorcraft preparing pilots for commercial pilot certificate.—__________________

21F. Enter date your commercial balloon certificate was acquired.—____________________________________________________________________________

21G. Enter number of hours flight instruction given in airplanes preparing pilots for an ATP certificate, an instrument rating, or a type rating.—________________

21H. Enter number of hours flight instruction given in helicopters preparing pilots for an ATP certificate, an instrument rating, or a type rating.—_______________

21I. Enter number of pilot and/or flight instructor certification practical tests completed within the past year (as FAA Aviation Safety Inspector).—_____________

22. Work Experience—Describe your current or most recent work experience in Block 22A and work backwards. Use a separate block for each position described
(e.g., Block 22A, Block 22B, etc.). Describe all of your work experience in specific detail that pertains to your qualifications for the designation(s) sought. Describe
each applicable position you held during at least the past 5 years. You may describe work experience accrued more than 5 years ago. Include military service if your
military experience is pertinent to your application for an examiner designation.
22A. Name of Employer/Organization:

Telephone
Number (

)

Address:
City:
Job Title:

State:
Dates Employed (mo/yr):
From:

Zip Code:

Supervisor's Name:
To:

Reason for Leaving:
Description of Duties:

22B. Name of Employer/Organization:

Telephone
Number (

)

Address:
City:
Job Title:

State:
Dates Employed (mo/yr):
From:

Zip Code:

Supervisor's Name:
To:

Reason for Leaving:
Description of Duties:

22C. Name of Employer/Organization:

Telephone
Number (

)

Address:
City:

FAA Form 8710-10 (1-00)

State:

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Zip Code:

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Form Approved OMB No. 2120-0033
Job Title:

Dates Employed (mo/yr):
To:
From:

Supervisor's Name:

Reason for Leaving:
Description of Duties:

22D. Name of Employer/Organization:

Telephone
Number (

)

Address:
City:
Job Title:

State:
Dates Employed (mo/yr):
To:
From:

Zip Code:

Supervisor's Name:

Reason for Leaving:
Description of Duties:

22E. Name of Employer/Organization:

Telephone
Number (

)

Address:
City:
Job Title:

State:
Dates Employed (mo/yr):
To:
From:

Zip Code:

Supervisor's Name:

Reason for Leaving:
Description of Duties:

22F. Name of Employer/Organization:

Telephone
Number (

)

Address:
City:
Job Title:

State:
Dates Employed (mo/yr):
To:
From:

Zip Code:

Supervisor's Name:

Reason for Leaving:
Description of Duties:

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23. Briefly summarize your aviation activities and professional responsibilities that best qualify you to be a designated pilot examiner.—
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________

24. During the past 5 years, were you
fired from any job for any reason?—

27. Have you ever been imprisoned,

been on probation, or been on
parole?—
� YES
� NO
30. Have you ever been discharged from a military

service under other than honorable conditions?—
� YES
� NO

26. Are you now under charges for
any violation of law?—

25. Have you ever been convicted of
any felony violation?—

� NO
� YES
� YES
� NO
� NO
� YES
29. Have you ever been discharged from a military
28. Have you ever been convicted by a military
service under a General discharge?—
court-martial?—

� YES
� NO
� YES
� NO
31. If you answered "YES" to any questions in Blocks 24 through 30, you MUST enter the full details.
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________

32. Education and Training—

Are you a high school graduate?
Are you a GED graduate?

� YES
� YES

� NO
� NO

Name of High School:_______________________________Date Graduated (mo/yr):______________

Date received GED (mo/yr):__________________________

College and/or Technical Training Dates:

Name of School:

From (mo/yr):

Curriculum or Study Program:

Degree or Certificate Received:

To (mo/yr):

RELEASE OF INFORMATION AND CERTIFICATION STATEMENT—
—
Read this statement CAREFULLY.

After you read this statement, you MUST sign and date this application in black ink.

Under your signature, you MUST print or type your name.

¸ I understand that a false statement on any part of this application will be grounds for not approving this application, for rescinding my eligibility as an examiner
candidate, for not designating me, or terminating any designation I may receive.
¸ I understand that any information given may be investigated.
¸ I consent to the release of information regarding my personal and technical qualifications for designation as a pilot examiner by employers, schools, law
enforcement agencies, and other individuals and organizations, to investigators, employees of the Federal government, and persons not employed by the Federal
government to whom the FAA has delegated the authority to screen and approve or disapprove pilot examiner applicants.
¸ I understand that, if my application is accepted, approval for assignment to the national examiner candidate pool is dependent on my passing the examiner

predesignation knowledge test with a score of 80 percent or higher.

¸ I understand that assignment to the national examiner candidate pool does not guarantee selection or designation as a pilot examiner and that, if selected,

designation is dependent on satisfactory completion of a practical test (demonstration of competency) and satisfactory completion of the Initial Pilot Examiner

Standardization Seminar.

¸ I understand that my FAA accident/incident/violation history will be verified at each stage of the application process.
¸ I understand that designation as a pilot examiner is a privilege, not a right, and that any designation received may be terminated, revoked, or not renewed at any

time for any reason the FAA Administrator deems appropriate.

¸ I certify that, to the best of my knowledge and belief, all of my statements on this application are true, correct, complete, and made in good faith.

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33. Applicant's Signature —(Sign application in black ink.)
—NOTICE—
—Whoever in any matter within the jurisdiction of any department or agency of the
United States knowingly and willfully falsifies, conceals or covers up by any trick, scheme, or
device a material fact, or who makes any false, fictitious or fraudulent statements or
representations, or entry, may be fined up to $250,000 or imprisoned not more than 5 years, or
both. (18 U.S. Code Secs. 1001; 3571).

Date signed—
—(Month, Day, Year)

(Print or type your name under your signature.)

FAA Form 8710-10 (1/00)

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FOR NATIONAL EXAMINER BOARD USE ONLY
(For Original Issuance Only)

�

� Not Qualified

Accepted for Predesignation Testing

Predesignation Test Score:____________________

�

�

Approved for Pool

Date:_________________________
Date of Test:___________________

Disapproved for Pool

Date:___________________

Signature of NEB Official:___________________________________________ Title:______________________________________

Referred to:_____________________FSDO

�

Selected

�

Date:___________________

Declined

Date:___________________

FOR FSDO USE ONLY: FAA Form 8710-6 may be used for renewals, additional authorizations, and/or reinstatements.

� Approve
Inspector's Recommendation:
Reason for Disapproval (Attach additional sheets, if required.):

� Disapprove

The individual submitting this application has satisfactorily demonstrated competency to perform the duties of the following designation(s):

� PE
Aircraft Categories:

�

� CIRE

CE

� Airplane
� Rotorcraft
Additional Qualifications/Limitations (if any):

�

�

ATPE

�

Glider

�

FIE (Must have 1 year as CE/CIRE.)

Lighter-Than-Air

Inspector's
Signature:_________________________________________________ Date: ________________________

FSDO:_____________________

Regional Office:

�

Approve

�

Disapprove

Date: _____________________

Signature: ____________________________________________________________________

Routing Symbol: _____________________

FSDO:
Certificate of Authority Issued:

Date: ___________________________

Examiner Number: _______________________________________________

FSDO:

______________________

Expiration Date:

______________________

LOA(s) Issued:
_______________

_______________

________________

_________________

_________________

_________________

Additional FSDO's to be served by the examiner (if any):

FAA Form 8710-10 (1/00)

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