DD Form 2628 Request for Approval of Contractor Flight Crewmember

OMB No. 0704-0347
OMB approval expires

REQUEST FOR APPROVAL OF CONTRACTOR FLIGHT CREWMEMBER

The public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering
and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Information Management Division, 1155 Defense
Pentagon, Washington, DC 20301-1155 (0704-0347). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with
a collection of information if it does not display a currently valid OMB control number.

PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM TO THE GOVERNMENT FLIGHT REPRESENTATIVE.
1. FROM (Name and Address of Contractor's Requesting Official)
2. TO (Name and Address of Government Flight Representative)

D R A F T
3. CONTRACTOR'S REQUESTING OFFICIAL (CRO).
I have verified the records of (Crewmember's name)

and request that he/she be approved

as a (crew position)

for (Strike out all inapplicable) experimental/engineering/acceptance/

production/functional/support flights in
a. TYPED NAME (Last, First, Middle Initial)

type aircraft.
b. SIGNATURE

c. DATE SIGNED

4. INSTRUCTOR PILOT/FLIGHT EXAMINER (IP/FE)
I certify that the crewmember above has satisfactorily flown a proficiency flight check on (Date)
a. TYPED NAME (Last, First, Middle Initial)

.

b. SIGNATURE

c. DATE SIGNED

5. GOVERNMENT FLIGHT REPRESENTATIVE (GFR)
APPROVED

a. TYPED NAME (Last, First, Middle Initial)

b. SIGNATURE

c. DATE SIGNED

DISAPPROVED

DD FORM 2628, 20080428 DRAFT

PREVIOUS EDITION IS OBSOLETE.

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