3330-473 Supplemental Qualifications Statement for 1825 and 2181

FORM APPROVED OMB NO. 2120-0500

Supplemental Qualifications Statement
U.S. Department of Transportation
Federal Aviation Administration
1. Name (First, MI, Last)

FOR 1825 AND 2181 SERIES
2. Date of
Birth (Mo/Da/Yr)

3. Social Security
Number

5. PILOT RATING RECORD Indicate certificate privileges for the ratings listed
below by writing "A" for Airline Transport, "C" for Commercial or "P" for Private in
column 1. Write an "F" for Flight Instructor Rating in column 2, where appropriate
1 2
1 2
Type Ratings: (specify)
Airplane Single Engine Land
Glider
Airplane Single Engine Sea
Rotorcraft Helicopter
Airplane Multiengine Land
Rotorcraft Gyroplane
Airplane Multiengine Sea
Lighter-than-air Free
Instrument Airplane
Balloon
Instrument Helicopter
Lighter-than-air Airship

4. AIRMAN CERTIFICATES HELD
Type
Airline Transport Pilot
Commercial Pilot
Private Pilot
Flight Instructor

Date Issued

Certificate No.

6. TEST PILOT EXPERIENCE
Name of Company or Organization

Date Employed

Fixed
Wing
Hours

RotoCraft
Hours

Name of Company or Organization

Date Employed

Hours

Hours

Flight
Test
Pilot
Production
Test
Pilot

7. FAA DESIGNATIONS
AND AUTHORIZATIONS

8. TYPE AND TOTAL
FLIGHT HOURS
Date Issued

Designated Pilot Examiner
Pilot Proficiency Examiner
Designated Flight Engineer
Examiner
Designated Aircraft Dispatcher
Examiner
Check Airman
Aircrew Program Designee
Designated Airworthiness
Representative
Designated Manufacturing
Inspection Representative
Designated Engineering
Representative
Designated Parachute Rigger
Examiner

FAA Form 3330-47-3 (10/98)

Total Pilot Time
Single Engine
Twin Engine
Three or more Engine
Multiengine over 12,500 lbs maximum Certificated Takeoff Weight
Turbine Powered
Turbo Powered
Actual Instrument
Hood Instrument
Flight Simulator
Night
Total Flight Instructor
Instrument Instructor
Multiengine Instructor
Total in Last 12 Months
Total in Last 3 Years
Total in Last 5 Years

Total Hours Flown to Date
Airplane
PIC
SIC

Rotorcraft
PIC
SIC

9. AIRCRAFT
Make/Model/Series

Total Hours Flown to Date
Flt Engr
PIC
SIC