8710-6 Examiner Designation and Qualification Record

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 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 a benefit 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.
Form Approved OMB NO. 2120-0033
08/31/2013

TYPE OF DESIGNATION

PRIVATE PILOT

EXAMINER DESIGNATION
U.S. Department
of Transportation

AND QUALIFICATION RECORD

Federal Aviation
Administration
Attach supplemental sheets if more space is required for any item
1. NAME (Last, first, middle)

Telephone No.

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

COMMERCIAL PILOT EXAMINER
AIRLINE TRANSPORT PILOT EXAMINER
PROFICIENCY PILOT EXAMINER
FLIGHT ENGINEER EXAMINER
FLIGHT INSTRUCTOR EXAMINER
OTHER

3. DATE OF BIRTH (Month, day, and year)

4. U.S. CITIZEN
YES
NO

5. DO YOU NOW HOLD, OR HAVE YOU
EVER HELD, AN EXAMINER DESIGNATION

TYPE AND NUMBER
YES
NO
6. HAS ANY CERTIFICATE OR RATING ISSUED YOU EVER BEEN SUSPENDED OR REVOKED OR HAVE YOU PAID A CIVIL PENALTY AS A RESULT OF A VIOLATION OF
THE FEDERAL AVIATION REGULATIONS. (Complete for original designations only)
YES
NO
7. CERTIFICATES HELD
TYPE

CERTIFICATE NO.

RATINGS

DATE ISSUED

8. FLIGHT EXPERIENCE (in hours)
AIRPLANE
TOTAL

ROTORTYPE

LAST 12 MO

TOTAL

LAST 12 MO

GLIDERS
TOTAL

LAST 12 MO

AIRSHIPS
TOTAL

LAST 12 MO

INSTRUMENT
FLIGHT
(Actual or sim)

NIGHT
FLIGHT

PILOT-IN-COMMAND
FLIGHT INSTRUCTION GIVEN
COPILOT
FLIGHT NAVIGATOR
FLIGHT ENGINEER
9. EMPLOYMENT (Indicate professional experience pertinent to this designation)
EMPLOYER'S NAME

NATURE OF WORK

DATES

TITLE OF POSITION

10. SPECIAL TRAINING PERTINENT TO THE DESIGNATION

CERTIFICATION: I certify that I am familiar with the requirements for this designation, its privileges and limitations, and that the information stated herein is true. It is understood that this
designation may be terminated upon notice by the FAA for the reasons specified in section 183.15(c) of the Federal Aviation Regulations.

DATE

FAA Form 8710-6 (10-95) Supersedes Previous Edition

SIGNATURE

Electronic Forms (PDF)

NSN: 0052-00-036-7003

FOR FAA USE
DATE LAST REPORT
SUBMITTED

FLIGHT TEST ACTIVITIES-GENERAL AVIATION

TYPE OF ACTION

(Complete for renewals and additional designations)

ORIGINAL ISSUANCE

TOTAL
SUBMITTED

CERTIFICATES/RATINGS
RENEWAL

DISAPPROVED
BY
EXAMINER

ACCEPTED
BY
INSPECTOR

RECHECKED
BY
INSPECTOR

NO. RETURNED
FOR
CORRECTION

PRIVATE PILOT
COMMERCIAL PILOT

ADDITIONAL AUTHORITY

AIRLINE TRANSPORT PILOT
INSTRUMENT RATING

SPOT CHECK ONLYNO RENEWAL EFFECTED

PRIVATE

ADDITIONAL
RATINGS

REINSTATEMENT

COMMERCIAL
ATR

Complete for original issuance and
reinstatements only

CHARACTER AND REPUTATION (Include industry and community reputation as well as personal knowledge possessed by FAA personnel)

PROFESSIONAL ABILITY (Brief narrative description of examiner indoctrination and training given and results expressed as "'good," " excellent," or "unsatisfactory.")

APPROVE

INSPECTOR'S RECOMMENDATION/ACTION

DISAPPROVE

JUSTIFICATION FOR APPROVAL/REASONS FOR DISAPPROVAL

The individual named has been flight tested/examined and deemed competent to perform the duties of the designation indicated below.

DESIGNATION

CATEGORY
PRIVATE PILOT

ADDITIONAL QUALIFICATIONS LIMITATIONS (For pilot flight engineer examiner
give aircraft category)

AIRPLANE

COMMERCIAL PILOT EXAMINER
AIRLINE
PROFICIENCY PILOT EXAMINER
FLIGHT ENGINEER EXAMINER
FLIGHT INSTRUCTOR EXAMINER

ROTORCRAFT
GLIDER
AIRSHIP
OFFICE NO.

DATE

INSPECTOR'S SIGNATURE

PRIVACY ACT STATEMENT. The information on this form is solicited under authority of the Federal Aviation Regulations Pan 183. The purpose of this information is to establish your qualifications as an

examiner. Submission of the data is mandatory. Incomplete submission may result in delay or denial of your request. The data will be used to determine your eligibility as an examiner, and for statistical purposes.
In addition, the data also becomes part of the Privacy Act system of records DOT/FAA 830, Representatives of the Administrator, and is subject to the additional conditions of that published system.

CONCUR

DATE

REGIONAL OFFICE ACTION
SIGNATURE

DISAPPROVE
TYPE OF DESIGNATION
NO.
FAA Form 8710-6 (10-95) Supersedes Previous Edition

Electronic Forms (PDF)

CERTIFICATE OF AUTHORITY ISSUED
DO TO SERVE UNDER
EXPIRATION DATE
NSN: 0052-00-036-7003