Form FAA Form 8710-6 FAA Form 8710-6 Examiner Designation and Qualification Record

FAA Form 8710-6, Examiner Designation and Qualification Record
Supplemental Information
OMB CONTROL NUMBER: 2120-0033
EXPIRATION DATE: 07/31/2020

Privacy Act Statement
Privacy Act Statement (5 U.S.C. § 552a(e)(3)):
Authority: Information on Federal Aviation Administration (FAA) Form 8710-6,
Examiner Designation and Qualification Record is solicited under the authority of Title 14
of Code of Federal Regulations, Part 183 (14 CFR part 183).
Purpose: The purpose of collecting this information is to evaluate an application, to
establish an applicant’s qualifications as an examiner and to determine the applicant’s
eligibility.
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 77 FR 42796 - July 20, 2012 and 84 FR 55222 - October 15, 2019
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 2120-0022. 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

FAA Form 8710-6 (10/95) Supersedes Previous Edition
Detach this supplemental information before using the attached form

Form Approved OMB NO. 2120-0033
07/31/2020

TYPE OF DESIGNATION

PRIVATE PILOT

EXAMINER DESIGNATION
AND QUALIFICATION RECORD

U.S. Department
of Transportation
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

YES
NO

TYPE AND NUMBER

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(b) of the Federal Aviation Regulations.

DATE

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

SIGNATURE

Page 1

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 TRANSPORT PILOT EXAMINER

ROTORCRAFT

PROFICIENCY PILOT EXAMINER

GLIDER

FLIGHT ENGINEER EXAMINER
FLIGHT INSTRUCTOR EXAMINER

DATE

AIRSHIP
OFFICE NO.

CONCUR

DATE

INSPECTOR'S SIGNATURE

DISTRICT CERTIFICATE MANAGEMENT OR REGIONAL
SIGNATURE

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

Page 2

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