Form 8710-13 Remote Pilot Certificate and/or Rating Application

Form approved OMB No: 2120-0021

xx/xx/2016

TYPE OR PRINT ALL ENTRIES IN INK

Remote Pilot Certificate and/or Rating Application
I. APPLICATION INFORMATION (Mark ‘X’ in all the blocks applicable to the certificate or rating for which you are applying):
Ratings
Other Information/Requests
Small Unmanned Aircraft System

Initial

Recurrent

Other specify:

A. Name (Last, First, Middle)
E1. Residential Address

B. SSN (US Only)
(include City, State, Zip Code & Country)

C. Date of Birth

E2. Mailing Address (This address will be printed on the
permanent airman certificate, if different than block E1)

D. Place of Birth (City and State) or (City and Country)

MMDDYYYY

F. Citizenship / Nationality
USA
Other
specify:

G. Sex
Male
Female

H. Height (inches) I. Weight (pounds) J. Hair Color

K. Eye Color

L. Do you read, speak, write, and understand the English language? L1. If you answered “No” to question ‘L’, are you unable to read, speak, write, or understand the English
Yes
No
language due to medical reasons?
Yes
No If yes, please explain:
M. Do you hold, or have you ever held an FAA certificate? M1. Grade of Certificate
M2. Certificate Number
M3. Date Issued
Yes
No
M4. If you hold a Pilot Certificate, have you accomplished a flight review in accordance with §61.56(c)?
M5. Date of Last Flight Review
Yes
No
N. Have you ever been convicted for violation of any Federal or State statutes relating to narcotic drugs, marijuana, or depressant or stimulant drugs or substances?
Yes
No
Date of Final Conviction:
If you answered Yes, please explain:
O. Have you ever been denied a remote pilot certificate for any reason?

Yes

No

If yes, please explain:

II. CERTIFICATE OR RATING APPLIED FOR ON BASIS OF:
A. Completion of Knowledge Test (attach knowledge test results with application)
B. Completion of Training Course (attach training course completion certificate with application)
III. APPLICANT’S CERTIFICATION: I certify that all statements and answers provided by me on this application form are complete and true to the best of my knowledge and I agree that they are to be considered as part of the basis
for issuance of any FAA certificate to me. I have received the Pilot’s Bill of Rights Written Notification of Investigation that accompanies this form and have read and understand the Privacy Act statement that also accompanies this form.
Signature of Applicant

Date
MM/DD/YYYY

Submitting Official’s Report
I have personally reviewed this application and I certify that the individual meets the applicable requirements of 14 CFR Part 107 for the certificate or rating sought.
I have personally verified the applicant’s identification.
I have personally delivered the Written Notification under the Pilot’s Bill of Rights to the applicant.
Applicant meets FAA Aviation English Language Proficiency
Application Accepted

Temporary Certificate Issued

Yes

No

Application Rejected

Designated Examiner or Airman Certification Representative Signature
Date
Examiner’s Signature (Print Name & Sign)

specify:

Designation Number

Designation Expires

Aviation Safety Inspector or Technician Signature
Date
Inspector’s Signature (Print Name & Sign)

Certificate Number

FAA Office Code

Authorized Instructor Signature
Date
Instructor’s Signature (Print Name & Sign)

Certificate Number

Certificate Expires

Attachments:

Certificate Number

Airman’s Identification(ID) (US Driver’s License or passport recommended)) Applicant Information

Knowledge Test Report

Form of ID

Name

Training Course Completion Certificate

ID Number

Date of Birth

Temporary Certificate

Expiration Date

Certificate Number

Telephone Number

E-mail Address

Other specify:

Remarks

FAA Form 8710-13 (06-xx)

Electronic Version Only

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