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

U.S. Department
of Transportation

INFORMATION FOR APPLICANT

Federal Aviation
Administration

STATEMENT OF
QUALIFICATIONS
(DAR - 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: A federal agency may not conduct or sponsor, and a
person is not required to respond to, nor shall a person be subject to a penalty for failure to
comply with a collection of information subject to the requirements of the Paperwork Reduction
Act unless that collection of information displays a currently valid OMB Control Number. The
OMB Control Number for this information collection is 2120-0033. Public reporting for this
collection of information is estimated to be approximately 30 minutes to 1 hour per response,
including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, completing and reviewing the collection of information. All
responses to this collection of information are required to obtain or retain benefits per 14 CFR
Part 183. Send comments regarding this burden estimate or any other aspect of this collection
of information, including suggestions for reducing this burden to the FAA at: 800 Independence
Ave. SW, Washington, DC 20591, Attn: Information Collection Clearance Officer, AES-200.

Tear off this cover sheet before submitting this form.
FAA Form 8110-14 (1/12) Supersedes Previous Edition

FAA Form 8110-14, Statement of Qualifications
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.
OMB-2120-0033
Expiration Date 08-31-2013
3. U.S. CITIZEN

STATEMENT OF QUALIFICATIONS
(DAR-DMIR-DER)

US Department of Transportation
Federal Aviation Administration

INSTRUCTIONS: Print or type all entries except signatures

Yes

No

1. NAME (Last, first, middle) OR ORGANIZATION
4. DATE OF BIRTH

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

6. BUSINESS FAX NUMBER

7. EMAIL ADDRESS

8. DESIGNATION SOUGHT
Designated Engineering
Representative (DER)

Structural Engineering

Engine Engineering

Powerplant Engineering

Propeller Engineering

Company

Systems and Equipment Engineering

Flight Analyst

Consultant

Flight Test Pilot

Acoustical Engineering

Note:

Manufacturing Function(s)
Designated Airworthiness Representative (DAR)

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

Designated Manufacturing Inspection Representative (DMIR)
Applicants shall identify specific function(s) for which appointment is sought:

9. 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

10. EDUCATION AND TRAINING HIGH SCHOOL LEVEL AND ABOVE PERTINENT TO DESIGNATION SOUGHT.
Dates
From
To
Name of School
Curriculum or Study Program

11. FAA CERTIFICATES NOW HELD PERTINENT TO DESIGNATION SOUGHT.
Type
Certificate No.
Rating

Degrees Received

Date Each Rating Issued

12. EMPLOYER’S RECOMMENDATION:
I recommend the person identified above be appointed as:
Designated Engineering Representative
Date

Designated Airworthiness Representative

Designated Manufacturing Inspection
Representative

Primary Business

Signature

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

EMAIL Address (Optional)

14. 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 (1-12) Supersedes Previous Edition

Signature
Electronic Format PDF