Form 8520-2 Aviation Medical Examiner Designation Application

OMB Control Number 2120-0604
Expiration Date 4/30/11

AVIATION MEDICAL EXAMINER
DESIGNATION APPLICATION
PAPERWORK REDUCTION ACT STATEMENT
This information is collected to assist the agency in evaluating physicians who ask for authority to conduct medical examinations of
person applying for airman medical certification This information will further the agency's performance in screening and selecting
individuals for designation as Aviation Medical Examiners (AMEs) The burden of the collection is estimated to average 30 minutes per
request This information is considered mandatory, is collected only when the applicant wishes to become an AME, and is solicited
under the Authority of 49 U S C 44702 and 14 CFR Part 183
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 is 2120-0604 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, AES-200
PRIVACY ACT STATEMENT
The information on this form is solicited under the authority of 49 U S C 44702 and 14 CFR Part 183
No designation as an AME may be made unless a completed application form has been received (14 CFR 183)
This information is to permit consideration of the applicant's qualifications and suitability to act as an AME for the FAA It also is used
for publication of AME directories and for other statistical purposes
The information collected on the form becomes part of the Privacy Act System of Records, DOT/FAA 822, Aviation Medical Examiner
System
Submission of your Social Security Number (SSN) is not required by law and is voluntary Refusal to furnish your SSN will not result in
the denial of any right or privilege provided by law Your SSN is solicited to assist in performing the agency's functions under the
authority of 49 U S C 44702, and if supplied, will be used to query national and/or state medical practitioner data banks to verify your
medical credentials If you refuse to supply your SSN, a substitute system of identification will be necessary to permit the required
query
INSTRUCTIONS
1 Submit your application in duplicate to the FAA Regional Flight Surgeon (RFS) for your locality Additional copies of this form can be
downloaded at http //feds faa gov Please remember to retain a copy for your file
2 You can find applicable Regional Flight Surgeon Office addresses at http //www cami iccbi gov, if needed
3 Retain this instruction sheet for your files since it contains the conditions of your designation
4 Please attach to your application copies of your medical school diploma, certificate of any postgraduate professional training,
medical specialty board certification (if any), and certification of current unrestricted valid state hcense(s) to practice medicine
GENERAL INFORMATION
The FAA uses an Aviation Medical Examiner (AME) System to conduct medical examinations of airmen and apply medical standards
prescribed in the Federal Aviation Regulations (FARs) AMEs are authorized to assess airman fitness and to issue, defer or deny
issuance of FAA medical certificates The responsibility and trust associated with designation as an AME may necessitate investigation
to determine the applicant's personal and professional suitability The information requested on this application may be used to
facilitate that investigation
Only fully licensed physicians in good standing in their communities are designated as AMEs on the basis of training and experience,
adequacy of facilities for performing the prescribed examinations, and the need for examiners in the geographic area Training or
experience in a particular medical specialty may sometimes be required because of particular agency needs

FAA Form 8520-2 (5-09) Supersedes Previous Edition

NSN 0052-00-035-9005

OMB Control Number 2120-0604
Expiration Date 4/30/11
AVIATION MEDICAL EXAMINER
DESIGNATION APPLICATION
GENERAL INFORMATION (CONTINUED)
Designation as an AME authorizes the physician to perform the medical examination of commercial pilots (second-class) and student
and private pilots (third-class), and to issue, defer, or deny issuance of FAA medical certificates Designation as a senior AME-to
examine airmen of all classes, including airline transport pilots (first-class)-usually requires 3 years experience as an AME and
additional equipment All designations are for 1 year and, in addition to other criteria specified in FAA Order 8520 2E as amended,
renewal is contingent upon the interest of the AME, accuracy and number of examinations performed, and compliance with AME
training requirements The FAA makes final determination relative to the designation of the AME
The FAA does not supply any medical equipment needed in the conduct of medical examinations except the Near and Intermediate
Vision Acuity Chart but will furnish complete examination instructions and forms In addition to those items normally needed for
performance of a general medical examination, the equipment listed in Appendix 2 of FAA Order 8520 2E in the "Guide for Aviation
Medical Examiners", as amended, is required (The equipment list may also be viewed at www
) Upon notification of your
acceptance as an AME, and before final designation, you will be asked to certify that FAA acceptable equipment has been acquired
Most of the required medical equipment may be obtained from local medical supply companies
CONDITIONS OF DESIGNATION AS AN AME
As conditions of designation as an AME, the designee must
1 Become thoroughly familiar with instructions regarding evaluation and documentation of medical history Become familiar with
instructions concerning the proper technique of medical examination of airmen Consider the aviation medical significance of all
medical tests, laboratory reports, consultation reports, and other medical information available Become familiar with the provisions of
14 CFR Part 67, FAA Order 8520 2E, and the instructions in the "Guide for Aviation Medical Examiners" Considering all medical
information available, be able to make a proper decision to issue, defer or deny airman medical certification,
2 Abide by the rules and regulations of the FAA,
3 Personally take medical history of and perform the medical examination of applicants for airman medical certificates Under certain
circumstances other personnel may be permitted to perform the paraprofessional portion of such examinations, but regardless of who
performs the tests, the AME is responsible for the accuracy of the findings, and this responsibility may not be delegated,
4 Use the Airman medical Certification System (AMCS) for the recording, validation, and transmission of airman medical certification
data Detailed information on the AMCS may b obtained by contacting the AMCS hotline at (405) 954-3238,
5 Keep current in the practice and science of changes in aerospace medicine,
6 Complete FAA-sponsored Medical Certification Standards and Procedures Training (MCSPT) Clinical Aerospace Physiology
Review for AMEs (CAPAME), and a Basic AME Seminar prior to designation and subsequently complete an AME Seminar or other
equivalent training every 3 years,
7 Assure that a member of the AME's staff completes MCSPT before the AME is initially designated,
8 Inform the FAA of any change of address, telephone, Fax number, or e-mail address,
9 Inform the FAA of any investigation, indictment, or pending action in any local, state, or Federal Court, and
10 Inform the FAA of any action against the AME's medical license by a State licensing board or the Drug Enforcement Administration
(DEA), or of any action to remove or restrict the AME's medical privileges by an hospital or specialty board or the DEA
If at any time after designation there is discovered any error, omission, or misrepresentation or concealment of material fact in this
application this will be regarded as sufficient reason for the termination of such a designation

FAA Form 8520-2 (5-09) Supersedes Previous Edition

NSN 0052-00-035-9005

OMB Control Number 2120-0604

©

AVIATION MEDICAL EXAMINER
DESIGNATION APPLICATION

US Department of Transportation
Federal Aviation Administration
Type or Print All information

Check box(es) and/or complete items as applicable

Use additional pages, as

necessary

A. APPLICANT IDENTIFICATION
1a

Name (Last, First, Middle)

b

r n Male

V~\ Female 9 Degree(s) Check all that apply

[]MD

\Z\DO

QPhD

QMPH

Q MS

Q]_
Other

2 Date of Birth (Mo/Day/Yr)

3 SSN (optional)

10 Primary Medical Specialty (Only one primary specialty is permitted in this space)

4 Address Where Examinations Will Be Performed
a Name of Institution / Clinic, If Any
11 List any Secondary Specialties in order of importance to your practice
b Street Address
c City

d State/Province

e ZIP Code

f County

g Country

5 a Office Telephone Number

b Office FAX Number

6 E-mail Address
7 If you have previously been designated as an AME, list AME Number and Region
8 List all past and present State Medical Licenses and License Numbers (State Abbreviation / License number / Period of Licensure)
B. EDUCATION
City/State

Name of School(s)

Mo/Day/Yr Graduated

Degree Received

€5
Name of Hospital/lnstitution(s)

City/State

Inclusive Dates

Type

Name of Institution(s)

City/State

Inclusive Dates

Degree/Certificate

JZ c
X 0)

F "O

C. EXPERIENCE
1. MEDICAL
a Type of Practice

c Years
b Institution(s) (Name and location)

From

To

2. AVIATION (Check all that apply)
f j Private Pilot
| | Certified Flight Instructor
| | Commercial Pilot
recertified Instrument Flight Instructor
[~J Other (Specify)
| | Airline Transport Pilot
3. MILITARY (Current or past status)
Branch

| | Active Duty

From

To

I | Reserves
I I National Guard
Flight Surgeon9

fjYes

QNO

Number of Years of Flight Medicine Practice _
D. SPECIALTY BOARDS/MEDICAL SOCIETIES

FAA Form 8520-2 (8-05)

Supersedes Previous Edition

NSN 0052-00-035-9005

O M B Control Number 2120-0604
E. GENERAL INFORMATION
PLEASE ANSWER THE FOLLOWING QUESTIONS
(if you check "Yes", explain in detail under remarks)

YES

9

1

Is any license of yours to practice medicine/surgery restricted in any w a y

2

Has any license of yours to practice medicine/surgery ever been restricted, suspended, or revoked 9

3

Has any application for renewal of any license of yours to practice medicine/surgery ever been denied 9

4

Has the Drug Enforcement Administration ever proposed or taken any action against you that would restrict your ability to practice
medicine/surgery 9

5

Has any action ever been taken to restrict your privilege to practice medicine/surgery by a hospital or specialty b o a r d 9

6

Have you ever been charged with a violation of any local, state, or Federal law pertaining to controlled or habit-forming drugs or narcotics 9

7

Have you ever been convicted of a felony 9

8

Are there any investigations, charged indictments, or pending actions against you in any local, state, or federal court that could result in
any of the events cited in questions 1 through 7, a b o v e 9

•
•
•
•
•
•
•
•

NO

•
•
•
•
•
•
•
•

F. REMARKS
Reference

item numbers

when explaining

previous entries and when attaching

information.

G. CERTIFICATION
I hereby certify that the information provided herein and in attachments is true and correct to the best of my knowledge and belief
I agree to the conditions of designation which accompany this application It is further agreed that all necessary equipment will be acquired upon acceptance
a n d PRIOR to my conduct of FAA medical examinations
W A R N I N G : 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 US Code Sees
1001,3571)
Applicant Typed or Printed Name

Date

Signature

H. FAA USE ONLY
T h i s application has been reviewed and references have been investigated and/or it has otherwise been determined that the applicant
|

| Meets

|

| Designation not made for the following reasons:

Q

Does not meet the professional standards required for designation as an AME

Serial Number

Applicant Designated A s :
|

| Senior Aviation Medical Examiner

|

| Aviation Medical Examiner

Date Designation Action Completed

Date Applicant's Acceptance Received

Region

Regional Flight Surgeon/Authorized Representative

Date

Date Supplies/Instructions Issued

Signature
Original Received in AAM-400
Date

FAA Form 8520-2 (8-05)

Supersedes Previous Edition

By

NSN 0052-00-035-9005