General Aviation DPE, SAE, and Admin-PE Applicants

Representatives of the Administrator, 14 CFR part 183

DPE SIS

General Aviation DPE, SAE, and Admin-PE Applicants

OMB: 2120-0033

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DPE SUPPLEMENTAL INFORMATION


This sample document, or a similar format may be used to provide supplemental information to support eligibility, and qualifications for appointment as a FAA Designated Pilot Examiner (DPE).


Describe your experience that pertains to qualifications for a Designated Pilot Examiner (DPE). Please be detailed in your responses in order to support your experience. Refer to FAA Order 8000.95 Designee Management System, Volume 3 for minimum experience requirements for a DPE. You may attach additional experience pages as necessary.


Name of Employer/Organization:

Telephone Number:

Street Address:

City:

State (Country if other than USA):

Zip/Postal Code:

Job/Position Title:

Dates Employed:

From: ________________ To:___________________

Supervisor’s Name:

FAA Air Agency or Air Operator Certificate Number

(If applicable):

Experience (add additional pages if needed):


Name of Employer/Organization:

Telephone Number:

Street Address:

City:

State (Country if other than USA):

Zip/Postal Code:

Job/Position Title:

Dates Employed:

From: ________________ To:___________________

Supervisor’s Name:

FAA Air Agency or Air Operator Certificate Number

(If applicable):

Experience (add additional pages if needed):

Name of Employer/Organization:

Telephone Number:

Street Address:

City:

State (Country if other than USA):

Zip/Postal Code:

Job/Position Title:

Dates Employed:

From: ________________ To:___________________

Supervisor’s Name:

FAA Air Agency or Air Operator Certificate Number

(If applicable):

Experience (add additional pages if needed):

Name of Employer/Organization:

Telephone Number:

Street Address:

City:

State (Country if other than USA):

Zip/Postal Code:

Job/Position Title:

Dates Employed:

From: ________________ To:___________________

Supervisor’s Name:

FAA Air Agency or Air Operator Certificate Number

(If applicable):

Experience (add additional pages if needed):

Name of Employer/Organization:

Telephone Number:

Street Address:

City:

State (Country if other than USA):

Zip/Postal Code:

Job/Position Title:

Dates Employed:

From: ________________ To:___________________

Supervisor’s Name:

FAA Air Agency or Air Operator Certificate Number

(If applicable):

Experience (add additional pages if needed):

FAA Certificates Held


Provide the details of any FAA certificates held.


CERTIFICATE

TYPE

CERTIFICATE

NUMBER

RATINGS

DATE

OF ISSUANCE





































Flight Experience


Aircraft Category/Class

Total Pilot-in-Command

Pilot-in-Command in the Past 12 Months

Total Flight Instruction Given

Instrument Flight Instruction Given

Flight Instruction Given in the Past 12 Months (In Balloons)

Night Pilot-in-Command

Instrument Pilot-in-Command

Airplane Single-Engine Land








Airplane Multiengine Land








Airplane Single-Engine Sea








Airplane Multiengine Sea








Helicopter








Gyroplane








Glider








Balloon








Airship
















Large and Turbine Powered Aircraft Flight Experience

Enter turbine powered, large airplanes, and/or large helicopters.

Aircraft Make and Model

Pilot-in-Command Total



















File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleApplicant’s Name__________________________________________________
AuthorDOT/FAA
File Modified0000-00-00
File Created2024-10-29

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