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U.S.

Department of Transportation

Federal Aviation Administration

FAA Form 8710-1, Airman Certificate and/or Rating Application Supplemental Information and Instructions

Paperwork Reduction Act Statement:
The information collected on this form is necessary to determine applicant eligibility for airman ratings. We estimate it will take 15 minutes to complete this form. The information collected is required to obtain a benefit and becomes part of the Privacy Act system of records DOT/FAA 847, Aviation Records on Individuals. Please note that an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number associated with this collection is 2120-0021. Comments concerning the accuracy of this burden and suggestions for reducing the burden should be directed to the FAA at: 800 Independence Ave. SW, Washington, DC 20591, Attn: Information Collection Clearance Officer, AES-200.

See Privacy Act Information below. Detach this part before submitting form.
Instructions for completing this form (FAA 8710-1) are below. If an electronic form is not printed on a duplex printer, the applicant's name, date of birth, and certificate number (if applicable) must be furnished on the reverse side of the application. This information is required for identification purposes. The telephone number and E-mail address are optional. Tear off this cover sheet before submitting this form.

FAA Form 8710-1 (4-00) Supersedes Previous Edition

NSN: 0052-00-682-5007

date of issuance and certificate number. The information collected on this form will be included in a Privacy Act System of Records known as DOT/FAA 847. and the date.e. • Information relating to an airman’s physical status or condition used to determine statistically the validity of FAA medical standards.S. (b) Using contact information to inform airmen of meetings and seminars conducted by the FAA regarding aviation safety. • The status of the airman’s certificate (i. except for the Social Security Number.F. including the Department of Defense Commercial Airlift Division’s Air Carrier Analysis Support System (ACAS) for its use in identifying safety hazards and risk areas. a record from this system of records may be disclosed to the United States Coast Guard (Coast Guard) and to the Transportation Security Administration (TSA) if information from this system was shared with either agency when that agency was a component of the Department of Transportation (DOT) before its transfer to DHS and such disclosure is necessary to accomplish a DOT.04 or greater breath alcohol concentration. (m) Making airman. which is voluntary. and the Federal Parent Locator Service that locates noncustodial parents who owe child support. to Federal agencies. (l) Making records of past airman medical certification history data available to Aviation Medical Examiners (AMEs) on a routine basis so that AMEs may render the best medical certification decision. aircraft and operator record elements available to users of FAA’s Skywatch system. the aviation industry.R. administer the drug and alcohol testing programs of aviation entities. (i) Making records of an individual’s positive drug test result. local and tribal law enforcement agencies when engaged in an official investigation in which an airman is involved.C.S. (e) Providing information about enforcement actions. 44709 and 14 C. establishing and modifying support orders and location of obligors. targeting inspection efforts for certificate holders of greatest risk. (n) Other possible routine uses published in the Federal Register (see Prefatory Statement of General Routine Uses for additional uses (65 F. FAA Form 8710-1 (4-00) Supersedes Previous Edition . limitations. Submission of the data is mandatory. or orders issued thereunder. suspended or revoked for any reason). DOJ and other authorized Federal agencies. examples of basic information include: • The type of certificates and ratings held. 19477-78) For example. (j) Providing information about airmen through the Civil Aviation Registry’s Comprehensive Airmen Information System to the Department of Health and Human Services. unless requested by the airman to be withheld from public disclosure per 49 U. Department of the Treasury and the U. establishing paternity. Such records also contain the names and titles of individuals who. tracking and reporting aviation-related security events. (c) Disclosing information to the National Transportation Safety Board (NTSB) in connection with its investigation responsibilities. 44702. 44703.. or refusal to submit to testing required under a DOT-required testing program.C. including current and prospective employers of such individuals. and the public upon request.dot. class.C. TSA or Coast Guard function related to this system of records. for their use in managing. • The airman’s home address. titled “Aviation Records on Individuals” and will be subject to the routine uses published in the System of Records Notice (SORN) for DOT/FAA 847 (see www. (f) Making records of delinquent civil penalties owed to the FAA available to the U. in their commercial capacity.S. 5 USC § 552a: The authority for collecting this information is contained in 49 U.S. Office of Child Support Enforcement. Part 6 1 and 65. Failure to provide all required information will result in our being unable to issue you a certificate and/or rating. 44703(c). Records listed within the section on Categories of Records are retrieved using Connect: Direct through the Social Security Administration’s secure environment. (g) Making records of effective orders against the certificates of airmen available to their employers if the airmen use the affected certificates to perform job responsibilities for those employers. requests for exemption from medical requirements. modified. Department of Justice (DOJ) for collection pursuant to 31 U. Records in this system are used to identify airmen to the child support agencies nationwide in enforcing child support obligations. (d) Providing information about airmen to Federal.gov/privacy/privacyactnotices).R. available to third parties. §§ 40113.AIRMAN CERTIFICATE AND/OR RATING APPLICATION PRIVACY ACT STATEMENT: This statement is provided pursuant to the Privacy Act of 1974. (k) Making personally identifiable information about airmen available to other Federal agencies for the purpose of verifying the accuracy and completeness of medical information provided to FAA in connection with applications for airmen medical certification. and monitoring the effectiveness of targeted oversight actions. (h) Making airmen records available to users of FAA’s Safety Performance Analysis System (SPAS). alcohol test result of 0. whether it is current or has been amended.S. The principal purpose for which the information is intended to be used is to identify and evaluate your qualifications and eligibility for the issuance of an airman certificate and/or rating. 3711(g). the Department of Homeland Security (DHS). including: (a) Providing basic airmen certification and qualification information to the public upon request. including the Department of Defense (DoD). and restrictions of the latest physical • Information relating to an individual’s eligibility for medical certification. State. and requests for review of certificate denials.

Social Security Number. Enter your height in inches.e. Indicate if 142 training center. Block L. HAVE YOU FAILED A TEST FOR THIS CERTIFICATE OR RATING? Check appropriate block. As shown on the graduation certificate. The date you sign the application. As shown on the graduation certificate. Sex. CURRICULUM FROM WHICH GRADUATED.“No”. Name. 2.. green. 1. Date of Birth. B. enter the county and state.O. APPLICATION INFORMATION. Check for accuracy. Block D. Enter the number as it appears on your Block P. If not. so indicate. If block “U” was checked “Yes” give the date of final conviction. Do You Now Hold A Medical Certificate? Check yes or no. commercial. complete Blocks R. Block R. 4. Block B. enter the name of the city and country where you were born. 1. or III. NUMBER. blond. or grade and service number. Justification must be provided on a separate sheet of paper signed and submitted with the application when a PO Box or rural route number is used in place of your permanent physical address. Enter the name as shown on medical certificate. enter the make and model of each military aircraft used to qualify (as appropriate). Block O. In block 4a or 4b. etc. Total. 1st. AIRCRAFT TO BE USED. write and understand the English language? Check yes or no. i. Do NOT enter flight instructor certificate information. Eyes. Block V. be sure they are legible. enter the color of your hair under the wig or toupee. Identify the Training Curriculum. 1. All ratings that appear on the license.. Do not leave blank: Use only US Social Security Number.” Color should be listed as black. Certificate Number. use whole pounds only. CERTIFICATE OR RATING APPLIED FOR ON BASIS OF: Block A. 4. A. COUNTRY. Date Issued. Block C.e. DATE. Example: 5’8” would be entered as 68 in. or gray. however. or bottom of the boxes provided as appropriate. 07-09-1925 instead of July 9. Height. Use no more than one middle name for Block S. your rank. indicate. The way you normally sign your name. Holder of Foreign License Issued By. Block B. FAA policy requires that you use your permanent mailing address. Weight. enter the city and state where you were born. Block K. Do You Now Hold or Have You Ever Held An FAA Pilot Certificate? Check yes or no. Grade of Pilot Certificate. that ALL pilot time be entered. Night flying must be entered when required. (b) Pilot-In-Command Flight Time . If yes. DATE. Instruction received. The color should be listed as blue. (If flight test required) – Enter the make and model of each aircraft used. Flight Training Device and PCATD time may be entered in the boxes provided. Country which issued the license. Enter residence number and street. 1925. brown. SIGNATURE. i. indicate “Initial only. No fractions. Completion of Required Test. If you have an FAA certificate. II. Block T. enter the country where you are a citizen. Enter the grade of pilot certificate (i. V. check . Enter your weight in pounds. Date Issued. Block U. S. A map or directions must be provided if a physical address is unavailable. It is recommended. If you do not have a middle name. If you were born in the USA. black. If bald.25. 3.e. Permanent Mailing Address. You should fill in the blocks that apply and ignore the blocks that do not. Enter the class as shown on the medical certificate. (NOTE: A student pilot certificate is a “Pilot Certificate. Enter the date your medical certificate was issued. Date of graduation from indicated course. The City. i.In each make and model. Do not change the name on subsequent applications unless it is done in accordance with 14 CFR Section 61. Check for accuracy. Drugs. Private. Optional: See supplemental Information Privacy Act. Do you read. Graduate of Approved Course. Be sure the location is entered. Check USA if applicable. Block G. As shown on the graduation certificate. 3. Block E. and Instrument Time should be entered in the top. RECORD OF PILOT TIME.AIRMAN CERTIFICATE AND/OR RATING APPLICATION INSTRUCTIONS FOR COMPLETING FAA FORM 8710-1 I. 2nd. Student. Citizenship. 2. enter “NMN”. Box or rural route number in the top part of the block above the line. Block C.. Block M.) – (a) Enter the total Flight Time in each make and model. Block F. Block Q. Recreational. Date program was completed. Check appropriate blocks(s). Block H. If you have been charged with a violation which has not been adjudicated. Enter eight digits. RATINGS. hazel. Enter either “SSN” or the words “Do not Use” or “None. Commercial. APPLICANT’S CERTIFICATION. Make sure the numbers are not transposed. Block D. If you have a middle initial only. Date of Final Conviction.. use whole inches only. or 3rd class. brown. enter “Bald. middle.” SSN’s are not shown on certificates. red. Class of Certificate. Use numeric characters. Spell out the color of your eyes. Military Competence Obtained In. FAA Form 8710-1 (4-00) Supersedes Previous Edition NSN: 0052-00-682-5007 . 2. Place of Birth. Completion of Air Carrier’s Approved Training Program. IV. Check appropriate block. Flight Simulator. date rated as a military pilot.e. or gray. Hair.”) Block N. The minimum pilot experience required by the appropriate regulation must be entered. Check to see that DOB is the same as it is on the medical certificate. Only check “Yes” if you have actually been convicted. Block I. If you wear a wig or toupee. If the city is unknown. Name of Air Carrier. Spell out the color of your hair. AGENCY SCHOOL/CENTER CERTIFICATION NUMBER.” If you are a Jr. and T. speak. Approved course graduate must also complete Block “A” COMPLETION OF REQUIRED TEST. 3. Check male or female. private. NAME AND LOCATION OF TRAINING AGENCY/CENTER. Grade of license issued. or ATP). Enter the date your pilot certificate was issued. State. Enter your branch of service. III. record purposes. pilot certificate. and ZIP code go in the bottom part of the block below the line. Second In Command “SIC” time used may be entered in the appropriate blocks. P. the name on the application should be the same as the name on the certificate unless you have had it changed in accordance with 14 CFR Section 61. Enter legal name. If you were born outside the USA. Name of Examiner. 1. Block E. Narcotics. Number which appears on the license. TOTAL TIME IN THIS AIRCRAFT (Hrs. If simulator or FTD. 2. Block J..25. If decimal points are used. No fractions. GRADE OF LICENSE. Block A. or a II.

Date Issued T. Completion of Required Test Military Competence Obtained In 1. Have you ever been convicted for violation of any Federal or State statutes relating to narcotic drugs. Do you hold a Medical Certificate? Yes No R. or have you ever held an FAA Pilot Certificate? Yes No N. speak. Completion of Air Carrier's Approved Training Program 1.TYPE OR PRINT ALL ENTRIES IN INK Form Approved OMB No: 2120-0021 09/30/2010 DEPARTMENT OF TRANSPORTATION FEDERAL AVIATION ADMINISTRATION Airman Certificate and/or Rating Application Airline Transport Balloon Ground Instructor Airship Instrument Glider Powered-Lift l Application Information Student Recreational Private Commercial Additional Rating Airplane Single-Engine Airplane Multiengine Rotorcraft Flight Instructor ____ Initial ____ Renewal ____ Reinstatement Additional Instructor Rating Medical Flight Test Reexamination Reissuance of ____________________________ certificate B. Name of Examiner U. Name (Last. State. write. & understand the English language? Yes K. Total time in this aircraft / SIM / FTD hours 1. Date Rated 2b. SSN (US Only) C. Pilot in command hours 3. US Military PIC & Instrument check in last 12 months (List Aircraft) C. Service 2. Curriculum From Which Graduated 3. Do you read. Date of Final Conviction II. Have you failed a test for this certificate or rating? Yes No V. 4b.) Total Instruction Received Solo Cross Country Solo Cross Country PIC PIC SIC PIC SIC PIC SIC Instrument Night Instruction Received Night Take-off/ Landings Night PIC Night Take-Off/ Landing PIC PIC SIC PIC SIC PIC SIC Number of Flights Number of Aero-Tows Number of Ground Launches Number of Powered Launches PIC SIC PIC SIC PIC SIC Airplanes Rotor­ craft Powered Lift Gliders Lighter Than Air Simulator Training Device PCATD SIC PIC SIC PIC SIC IV. Date D. Aircraft to be used (if flight test required) 2a. First. Number 4. I have also read and understand the Privacy Act statement that accompanies this form. Eyes L. Grade of License 3. Holder of Foreign License Issued By 1. Graduate of Approved Course 1. or depressant or stimulant drugs or substances? Yes No V. Country 2. Middle) E. Flown 10 hours PIC in last 12 months in the following Military Aircraft. marijuana. Date 3. Place of Birth A. Hair Female M. Zip Code H. Signature of Applicant Date FAA Form 8710-1 (4-00) Supersedes Previous Edition NSN: 0052-00-682-5007 . Address F. Date of Birth Month Specify Other ________________ I. Rank or Grade and Service Number B. Weight Other ______________________ Day Year D. Ratings E. Class of Certificate S. Name of Air Carrier 2. Grade Pilot Certificate O. Name and Location of Training Agency or Training Center 1a. Applicants's Certification -. Certificate or Rating Applied For on Basis of: A. 4a. Date Issued Q. Which Curriculum Initial Pilot in Command (PIC) PIC Cross Country Instruction Received Upgrade Transition III RECORD OF PILOT TIME (Do not write in the shaded areas. Do you now hold. Sex Male No City. Height J.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. Certificate Number P. Certification Number 2. Citizenship USA G.

Date Inspector's Signature (Print Name & Sign) Certificate No. AAM-330 Training Course (FIRC) Name Instructor Renewal Based on Activity Test Training Course Duties and Responsibilities Date Graduation Certificate No.(s) Student Pilot Certificate Issued Examiner's Recommendation Accepted Rejected Certificate or Rating Based on Military Competence Foreign License Approved Course Graduate Other Approved FAA Qualification Criteria Flight Instructor Renewal Reinstatement Ground Instructor Reissue or Exchange of Pilot Certificate Special Medical test conducted -. State) Ground Certificate or Rating for Which Tested Type(s) of Aircraft Used Disapproved -.Temporary Certificate Issued (Original Attached) Disapproved -.Temporary Certificate Issued (Original Attached) Location of Test (Facility. Approved -. Date Agency Name and Number Officials Signature Title Air Agency's Recommendation Designated Examiner or Airman Certification Representative Report Student Pilot Certificate Issued (Copy attached) I have personally reviewed this applicant's pilot logbook and/or training record.Instructor's Recommendation Date I have personally instructed the applicant and consider this person ready to take the test. policies. I have personally tested and/or verified this applicant in accordance with pertinent procedures and standards with the result indicated below. I have personally reviewed this applicant's graduation certificate.Disapproval Notice Issued (Original Attached) Location of Test (Facility. City. and certify that the individual meets the pertinent requirements of 14 CFR Part 61 for the certificate or rating sought.(s) Designation No.report forwarded to Aeromedical Certification Branch. City. and have returned the certificate. Designation Expires Evaluator's Record (Use For ATP Certificate and/or Type Ratings) Inspector Oral Approved Simulator/Training Device Check Aircraft Flight Check Advanced Qualification Program Examiner Signature and Certificate Number _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ Date __________________________ __________________________ __________________________ __________________________ Aviation Safety Inspector or Technician Report I have personally tested this applicant in accordance with or have otherwise verified that this applicant complies with pertinent procedures. Instructor's Signature (Print Name & Sign) Certificate No: Certificate Expires The applicant has successfully completed our _________________________________________________________course. standards. State) Ground Certificate or Rating for Which Tested Date Examiner's Signature (Print Name & Sign) Type(s) of Aircraft Used Certificate No. and or necessary requirements with the result indicated below. Duration of Test Simulator/FTD Flight Registration No. and found it to be appropriate and in order.Disapproval Notice Issued (Original Attached) Duration of Test Simulator/FTD Flight Registration No. and is recommended for certification or rating without further _____________________________________________test. FAA District Office Attachments: Student Pilot Certificate (Copy) Knowledge Test Report Temporary Airman Certificate Notice of Disapproval Superseded Airman Certificate FAA Form 8710-1 (4-00) Supersedes Previous Edition Airman's Identification (ID) __________________________________________________ Form of ID __________________________________________________ Number __________________________________________________ Expiration Date __________________________________________________ Telephone Number ID: Name: _____________________________________________ Date of Birth: _______________________________________ Certificate Number: __________________________________ E-Mail Address ______________________________________ NSN: 0052-00-682-5007 Electronic Version (Adobe) . Approved -.