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Form Approved OMB No: 2120-0021

09/30/2010

TYPE OR PRINT ALL ENTRIES IN INK

Airman Certificate and/or Rating Application

DEPARTMENT OF TRANSPORTATION

FEDERAL AVIATION ADMINISTRATION

l Application Information

Student

Recreational

Private

Commercial

Airline Transport

Instrument

Additional Rating

Airplane Single-Engine

Airplane Multiengine

Rotorcraft

Balloon

Airship

Glider

Powered-Lift

Flight Instructor ____ Initial ____ Renewal ____ Reinstatement

Additional Instructor Rating

Ground Instructor

Medical Flight Test

Reexamination

Reissuance of ____________________________ certificate

Other ______________________

A. Name (Last, First, Middle)

B. SSN (US Only)

C. Date of Birth

D. Place of Birth

Month

Day

Year

E. Address

F. Citizenship

Specify

G. Do you read, speak, write, & understand

the English language?

USA

Other ________________

Yes

City, State, Zip Code

H. Height

I. Weight

J. Hair

K. Eyes

L. Sex

Male

Female

M. Do you now hold, or have you ever held an FAA Pilot Certificate?

N. Grade Pilot Certificate

O. Certificate Number

P. Date Issued

Yes

Q. Do you hold a

Yes

R. Class of Certificate

S. Date Issued

T. Name of Examiner

Medical Certificate?

U. Have you ever been convicted for violation of any Federal or State statutes relating to narcotic drugs, marijuana, or depressant or stimulant drugs or substances?

V. Date of Final Conviction

Yes

II. Certificate or Rating Applied For on Basis of:

1. Aircraft to be used (if flight test required)

2a. Total time in this aircraft / SIM / FTD

2b. Pilot in command

Completion of

Required Test

hours

1. Service

2. Date Rated

3. Rank or Grade and Service Number

Military

Competence

Obtained In

4a. Flown 10 hours PIC in last 12 months in the following Military Aircraft.

4b. US Military PIC & Instrument check in last 12 months (List Aircraft)

1. Name and Location of Training Agency or Training Center

1a. Certification Number

Graduate of

Approved

Course

2. Curriculum From Which Graduated

3. Date

1. Country

2. Grade of License

3. Number

Holder of Foreign

License

Issued By

4. Ratings

1. Name of Air Carrier

2. Date

3. Which Curriculum

Completion of Air

Carrier's Approved

Training Program

Initial

Upgrade

Transition

III RECORD OF PILOT TIME (Do not write in the shaded areas.)

Pilot

Cross

Night

Number of

Instruction

Country

Cross

Number of

Total

Solo

Instrument

Instruction

Take-off/

Night PIC

Take-Off/

Ground

Powered

Received

Command

Instruction

Country Solo

Country PIC

Flights

Aero-Tows

Received

Landings

Landing PIC

Launches

(PIC)

Received

PIC

Airplanes

SIC

PIC

Rotor

SIC

craft

PIC

Powered

SIC

Lift

Gliders

Lighter

Than Air

Simulator

Training

Device

PCATD

IV. Have you failed a test for this certificate or rating?

Yes

V. Applicants's Certification -- 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. I have also read and understand the Privacy Act statement

that accompanies this form.

Signature of Applicant

Date

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

NSN: 0052-00-682-5007