8110-14 Statement of Qualifications (DAR - ODAR - DMIR - DER)

INFORMATION FOR APPLICANT
U.S. Department
of Transportation

Federal Aviation
Administration

STATEMENT OF QUALIFICATIONS
(DAR—ODAR—DMIR—DER)

Privacy Act Statement
Information on this form is solicited under authority of 14 CFR Part 183. The purpose of this
information is to evaluate your application and establish your qualifications as a designee.
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 for the designation sought, and will become part of the Privacy Act system
of records DOT/FAA 830, Representatives of the Administrator, and is subject to the following
routine uses as published in the Federal Register: (1) To provide the public with the names and
addresses of certain categories of representatives who may provide service to them; and (2) DOT's
Prefatory Statement of General Routine Uses.
The submission of 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:
This collection of information is for the purpose of obtaining essential information
concerning the applicants’ professional and personal qualifications. The FAA uses the
information provided to screen and select the designees who act as representatives of the
Administrator in performing various certification and examination functions. The burden
associated with new and renewal applications using FAA Form 8110-14 is between 30
minutes and 1 hour. Providing this information is mandatory if a person wishes to apply to
become a Designated Representative. The information is protected under the provisions
of the Privacy Act and the Privacy Act system of records DOT/ FAA-830, Representatives
of the Administrator. 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 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.

Tear off this cover sheet before submitting this form.

FAA Form 8110-14 (6-00) Supersedes Previous Edition

N SN: 0052-00-047-2005

Organizations complete only the applicable blocks and attach separate resumes with the names, signatures, titles and qualifications of those persons
who would actually perform the authorized functions.

STATEMENT OF QUALIFICATIONS
(DAR—ODAR—DMIR—DER)

U.S. Department of Transportation
Federal Aviation Administration

Form A pproved OMB No. 2120-0033 04/30/2010

3. U.S. CITIZEN
� Yes

� No

INSTRUCTIONS: Print or type all entries except signatures

1. NAME (Last, first, middle) OR ORGANIZATION

4. SOCIAL SECURITY NO.

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

5. DATE OF BIRTH

6. BUSINESS PHONE NUMBER

8. EMAIL ADDRESS

7. BUSINESS FAX NUMBER

9. DESIGNATION SOUGHT
� Designated Engineering

Representative (DER)

� Company
� Consultant
� Manufacturing:

� Structural Engineering
� Powerplant Engineering
� Systems and Equipment Engineering
� Acoustical Engineering

� Engine Engineering
� Propeller Engineering
� Flight Analyst
� Flight Test Pilot

NOTE:

� Designated Airworthiness Representative (DAR)
� Organizational Designated Airworthiness Representative (ODAR)
� Designated Manufacturing Inspection Representative (DMIR)

A separate application must be submitted for each discipline, i.e.,
Manufacturing or Engineering.

Applicants shall identify specific function(s) for which appointment is sought:

10. EXPERIENCE RESUME FOR NUMBER OF YEARS, AS APPROPRIATE, PERTINENT TO DESIGNATION SOUGHT.

(Use additional sheets if

necessary)

Dates
From

To

Employer's Name

Position Title and Duties

11. EDUCATION AND TRAINING HIGH SCHOOL LEVEL AND ABOVE PERTINENT TO DESIGNATION SOUGHT.
Dates
From

To

Name of School

Curriculum or Study Program

Degrees Received

12. FAA CERTIFICATES NOW HELD PERTINENT TO DESIGNATION SOUGHT.
Type

Certificate No.

Rating

Date Each Rating Issued

13. EMPLOYER'S RECOMMENDATION:
I recommend the person identified above be appointed as:
� Designated Engineering Representative

� Designated Manufacturing Inspection
Representative

Date

Primary Business

� Organizational Designated Airworthiness
Representative

14. LOCATION WHERE DESIGNEE FUNCTIONS WILL BE PERFORMED IF DIFFERENT THAN BLOCK 2.
Address
Telephone Number

Signature

EMAIL Address (Optional)

15. CERTIFICATION: I certify that the above statements are true to the best of my knowledge and that I am familiar with the Federal Aviation
Regulations pertinent to the designation sought.
Date
FAA Form 8110-14 (6-00) Supersedes Previous Edition

Signature
N SN: 0052-00-047-2005