Form FAA Form 8110-14 FAA Form 8110-14 Statement of Qualifications

Form Approved OMB No. 2120-0033
Expires: July 31, 2020

INFORMATION FOR APPLICANT

STATEMENT OF QUALIFICATIONS (DAR - DMIR - DER)
_________________________ Privacy Act Statement_________________________
Privacy Act Statement (5 U.S.C. § 552a(e)(3)):
Authority: Information on FAA Form 8110-14, Statement of Qualifications, is solicited
under the authority of Title 14 of Code of Federal Regulations, Part 183.
Purpose: The purpose of collecting this information is to evaluate an application, to
establish an applicant’s qualifications as a designee and to determine the applicant’s
eligibility for the designation sought.
Routine Uses: In accordance with the Privacy Act system of records DOT/FAA 830,
Representatives of the Administrator, this information is routinely used to provide the public
with the names and addresses of certain categories of representatives who may provide
service to them. The Department has also published 15 additional routine uses applicable
to all DOT Privacy Act systems of records. These routine uses are published in the Federal
Register at 84 FR 55222 - October 15, 2019 and 77 FR 42796 - July 20, 2012, and under
‘‘Prefatory Statement of General Routine Uses’’ (available at
http://www.transportation.gov/privacy/privacyactnotices).
Disclosure: Submission of the data is voluntary and will become part of Privacy Act
System of Records DOT/FAA 830 Representatives of the Administrator. Incomplete
submission may result in delay or denial of your request.
Paperwork Reduction Act Burden 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 90 minutes per response, including the time
for reviewing instructions, searching existing data sources, gathering and maintaining the
data needed, and completing and reviewing the collection of information.
All responses to this collection of information are required to obtain or retain a benefit under
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: Information
Collection Clearance Officer, Federal Aviation Administration, 10101 Hillwood Parkway,
Fort Worth, TX 76177-1524.
Tear off this cover sheet before submitting this form.

FAA Form 8110-14 (03/20) Supersedes Previous Edition

Electronic Format PDF

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.
Form Approved OMB No. 2120-0033
Expires: July 31, 2020
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
1. NAME (Last, first, middle) OR ORGANIZATION

Yes

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

No

4. DATE OF BIRTH

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

Acoustical Engineering

Flight Test Pilot

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

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

9. EXPERIENCE RESUME FOR NUMBER OF YEARS, AS APPROPRIATE, PERTINENT TO DESIGNATION SOUGHT. (Use additional sheets if
necessary)
Dates
From

Employer’s Name

To

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

Degrees Received

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

Certificate No.

Rating

Date Each Rating Issued

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

Designated Manufacturing Inspection
Representative

Primary Business

Designated Airworthiness
Representative
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 (03/20) Supersedes Previous Edition

Signature

Electronic Format PDF

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