DPE Supplemental Information Sheet

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