Form 2120-0574 General Aviation Awards Program Application Form

•
•
•
•

Aviation Maintenance Technician
Avionics Technician
Certificated Flight Instructor
FAA Safety Team Rep (ASC)

OMB No: 2120-0574

Made Possible By

Aircraft Electronics Association (AEA)
Aviation Maintenance Technician Society (AMT Society)
Aircraft Owners and Pilots Association (AOPA)
Aeronautical Repair Station Association (ARSA)
Experimental Aircraft Association (EAA)
Federal Aviation Administration (FAA)
General Aviation Manufacturers Association (GAMA)
Helicopter Association International (HAI)
National Association of Flight Instructors (NAFI)
National Association of State Aviation Officials (NASAO)
National Air Transportation Association (NATA)
National Business Aviation Association (NBAA)
Professional Aviation Maintenance Association (PAMA)
Women in Aviation International (WAI)
(Rev: May’07)

GENERAL AVIATION AWARDS PROGRAM
The General Aviation Awards Program is a cooperative effort between the Federal Aviation
Administration (FAA) and aviation industry sponsors to recognize annually outstanding individuals in
the fields of Avionics, Flight Instruction, and Maintenance. In addition, the program recognizes
outstanding individuals serving the FAA Safety Team (FAASTeam) as representatives. The awards
highlight the important roles these individuals play in promoting aviation safety, education, and
professionalism. Winners will be recognized locally, regionally and nationally. National winners will
be recognized during AirVenture-Oshkosh each July. There, they will also receive gifts and
merchandise provided by sponsors and contributors.
ELIGIBILITY
All candidates must have been actively working within their respective aviation fields for a minimum of
five (5) years prior to application / nomination. Candidates must also hold valid FAA airman
certificates appropriate to their respective fields if required. In addition:
A) Aviation Maintenance Technician candidates must be actively working within the United States
under FAR Part 65;
B) Avionics Technician candidates must be actively working within the United States with an FAA
certified Part 145 Repair Station;
C) Certificated Flight Instructor candidates must be actively working within the United States
under FAR Part 61, Part 141 or Part 142;
D) FAASTeam Representative candidates must be actively involved in the FAA Safety Team.
Prior time in the National Safety Program applies to the 5-year requirement.
Candidates will be judged based on sustained superior performance in their respective fields as well as
specific accomplishments and contributions to aviation safety, education, and professionalism.
APPLICATION / NOMINATION PACKAGE
The application / nomination package should include only the required components listed below. Any
additional information will be disregarded. Missing required components may lead to disqualification.
¾ The completed application / nomination form (2 pages) with supporting documentation for each
activity listed (please type or complete& print from Sponsors’ websites)
¾ Legible photocopy of a government-issued photo identification document
¾ Legible photocopies of both sides of all FAA-issued airman certificates and designations
¾ A 1- 3 page professional aviation oriented résumé
¾ A high-resolution JPEG image of the candidate at work in a professional setting
¾ A list of awards and other recognition earned by the candidate in the last five years
¾ Three (3) letters of nomination/recommendation (1 or 2 pages) stating why the candidate is
deserving of the award. The letters should be distributed in the following manner:
One (1) letter from a supervisor (employer, FPM, Chief CFI, DPE, etc)
One (1) letter from a peer or co-worker
One (1) letter from a client or student who is familiar with the candidate’s work
PROCEDURES & TIMELINES
All applications / nominations will first be submitted to local Flight Standards District Offices (FSDO).
¾ July 1st thru September 30th : Packets accepted at local FSDOs
¾ October 1st thru November 14th : Local (FSDO) judging for all four award categories
¾ November 15th : FSDO winners announced and forwarded to FAA Regional Offices
¾ November 16th thru December 31st : Regional judging for all four award categories
¾ January 1st : Regional winners announced and forwarded to AFS-8
¾ January & February: National judging by industry peers for all four award categories
¾ March 1st : National winners announced

GENERAL AVIATION AWARDS PROGRAM
APPLICATION / NOMINATION
______ Aviation Maintenance Technician

______ Avionics Technician

______ FAASTeam Representative

______ Certificated Flight Instructor

Candidate’s name: _________________________________________
first

middle

______________________________

last

preferred name

Street address: _______________________________________________________________________________
City: _____________________________________________State: ___________Zip+4: ____________________
Home phone: _________________________________Cell phone: _____________________________________
Work phone: _________________________________ Fax: ___________________________________________
E-mail(s): ___________________________________________________________________________________
Full-time employer: ___________________________________________________________________________
company
supervisor
Street address: _______________________________________________________________________________
City: ______________________________________________ State: __________ Zip+4: ___________________
Phone: ________________________ Fax: _____________________ E-mail: _____________________________
Part-time employer: ___________________________________________________________________________
company
supervisor
Street address: _______________________________________________________________________________
City: _______________________________________________ State: __________ Zip+4___________________
Phone: ________________________ Fax: _____________________ E-mail: _____________________________
Total years experience in the field: _______________________________________________________________
Local FSDO: _______________________ FAASTeam Program Mgr: __________________________________
Phone: ___________________ Fax: ___________________ E-mail: ___________________________________
Nominator’s name (if appropriate): ______________________________________________________________
first

middle

last

Relationship to nominee: _______________________________________________________________________
Phone(s): ___________________________ E-mail(s): _______________________________________________

Affidavit
I hereby attest that all information submitted herein is true, correct and complete. I understand that any misrepresentation of
facts may result in removal from award consideration. I authorize present and past employers, the Federal Aviation
Administration and law enforcement agencies to disclose to representatives of the General Aviation Awards program
information about me from the records in their possession, and to provide copies of that information as necessary.

Candidate’s signature: _________________________________________ Date: ____________________

(Rev: May’07)

GENERAL AVIATION AWARDS PROGRAM
Candidate’s Name: ___________________________________________
List representative examples of your involvement in each the following activity categories and include
supporting documentation for each example listed.
PROFESSIONAL ACTIVITIES for CFI, AMT or AVIONICS TECH
FAASTeam ACTIVITIES for FAASTeam Reps
(Work assignments, job responsibilities, instructional activities, research & development, media work, etc)

1. __________________________________________________________________________________
2. __________________________________________________________________________________
3. __________________________________________________________________________________
4. __________________________________________________________________________________
5. __________________________________________________________________________________
6. __________________________________________________________________________________
7. __________________________________________________________________________________
8. __________________________________________________________________________________
9. __________________________________________________________________________________
10. _________________________________________________________________________________
11. _________________________________________________________________________________
12. _________________________________________________________________________________
13. _________________________________________________________________________________
14. _________________________________________________________________________________
PRO BONO SERVICE TO THE AVIATION COMMUNITY
(Service on professional boards & committees, involvement in professional associations, mentoring others, youth
activities, Scouts, Young Eagles, AOPA Airport Support Network, EAA Technical Counselor, EAA Flight
Advisor, Civil Air Patrol, FAASTeam Representative [ASC], etc)

1. _________________________________________________________________________________
2. __________________________________________________________________________________
3. __________________________________________________________________________________
4. __________________________________________________________________________________
5. __________________________________________________________________________________
6. __________________________________________________________________________________
7. __________________________________________________________________________________
CONTINUING PROFESSIONAL EDUCATION & DEVELOPMENT
(Additional certificates/ratings, college/technical school classes, industry training/seminars, safety seminars, etc)

1. __________________________________________________________________________________
2. __________________________________________________________________________________
3. __________________________________________________________________________________
4. __________________________________________________________________________________
5. __________________________________________________________________________________
6. __________________________________________________________________________________
7. __________________________________________________________________________________
(Rev: May’07)

GENERAL AVIATION AWARDS PROGRAM
PREVIOUS NATIONAL WINNERS
Certificated Flight Instructors
2007 - Mike Gaffney
2006 - Rich Stowell
2005 - John Teipen
2004 - Doug Stewart
2003 - Jeff Edwards
2002 - Kirby Ortega
2001 - Phil Poynor
2000 - Greg Brown
1999 - David Faile
1998 - J C Boylls
1997 - James Trusty
1996 - Lou Wipotnik
Aviation Maintenance Technicians
2007 - Paul New
2006 - Joe Hawkins
2005 - Mike Branham
2004 - Gary Goodpaster
2003 - Tom Hendershot
2002 - Garry Conrad
2001 - Dwain Chase
2000 - Arthur Geissman
1999 - Harry Shannon
1998 - Gary Schandal
1997 - Leonard Beauchemin
1996 - Ralph Michalka

FAASTeam Reps / Safety Counselors
2007 – Cheryl DeFilippo
2006 – Gene Hudson
2005 - Michael Church
2004 - Walt Schamel
2003 - Maj Jim McDonald, USAF
2001 - Adrian Eichhorn
2000 - Hank Bruckner
1999 - Patrick Duncan
1998 - Michael Vivian
1997 - Johnny Summers
1996 - James Gardner
Avionics Technicians
2007 - Jerry Luttrull
2006 - Terry Markovich
2005 - Charles Hanner
2004 - Keith Lewis
2003 - Al Ingle
2002 - Brady Terry
2001 - Brenda Olson
2000 - Robert Lenert
1999 - Daniel Derby

CONTRIBUTORS LIST
The National General Aviation Awards program is made possible through generous contributions of the
following organizations and their assistance is gratefully acknowledged.
Aeronautical Repair Station Ass’n (ARSA)
Aircraft Electronics Ass’n (AEA)
Aircraft Owners and Pilots Ass’n (AOPA)
AOPA Air Safety Foundation
Aircraft Technical Publishers
Aviations Speakers Bureau/Rod Machado
Aviation Supplies & Academics (ASA)
Duncan Aviation
Experimental Aircraft Ass’n (EAA)
Federal Aviation Administration (FAA)
GARMIN International
General Aviation Manufacturers Ass’n (GAMA)

Gleim Publications, Inc
Gulfstream Aerospace Corporation
Helicopter Ass’n International (HAI)
Jeppesen
Meggitts/S-TEC
Nat’l Air Transportation Association (NATA)
Nat’l Association of Flight Instructors (NAFI)
Nat’l Association of State Aviation Officials (NASAO)
Nat’l Business Aviation Association (NBAA)
Professional Aviation Maintenance Ass’n (PAMA)
Women in Aviation International (WAI)

Paperwork Reduction Act Statement: The purpose of this collection is to gather nominations for the annual FAA Safety Team Representative of the Year
Award. Submission of this information is voluntary. We estimate that it will take 1 hour to complete the form, not including time required for gathering
additional information, if necessary. There are no questions of a sensitive nature and there is no assurance of confidentiality. An agency may not conduct,
and a person is not required to respond to, a collection of information unless that collection displays a currently valid OMB Control Number. OMB Control
Number for this collection is 2120-0574
(Rev: May’07)