Faa Form 8710 11 – Fill Out and Use This PDF

U.S. Department

of Transportation

Federal Aviation

Administration

FAA Form 8710-11, Airman Certificate

and/or Rating Application

Supplemental Information and Instructions

Paperwork Reduction Act 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 2120-0690. Public reporting for this collection of information is estimated to be approximately 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, completing and reviewing the collection of information. All responses to this collection of information are required to obtain a benefit under 14 CFR Part 61 and Part 183. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to the FAA at: 800 Independence Ave. SW, Washington, DC 20591, Attn: Information Collection Clearance Officer, AES-200.

Privacy Act

The information on the accompanying form is solicited under authority of Title 14 of the code of Federal Regulations (14 CFR), Part 61. The purpose of this data is to be used to identify and evaluate your qualifications and eligibility for the issuance of an airman certificate and/or rating. Submission of all requested data is mandatory, except for the Social Security Number (SSN) which is voluntary. Failure to provide all the required information would result in you not being issued a certificate and/or rating. The information would become part of the Privacy Act System of records DOT/FAA 847, Aviation Records on Individuals. The information collected on this form would be subject to the published routine uses of DOT.FAA 847. Those routine users are: (a) To provide basic airman certification and qualification information to the public upon request. (b) To disclose information to the National Transportation Safety Board (NTSB) in connection with its investigation responsibilities. (c) To provide information about airman apprehension of drug-law violators. (d) To provide information about enforcement actions arising out of violations of the Federal Aviation regulations to government agencies, the aviation industry, and the public upon request. (e) To disclose information to another Federal agency, or to a court or an administrative tribunal, when the Government or one of its agencies is a party to judicial proceeding before the court or involved in administrative proceedings before the tribunal.

Submission of your Social Security Number is voluntary. Disclosure of your SSN will facilitate maintenance of your records which are maintained in alphabetical order and cross references with your SSN and airman certificate number to provide prompt access. In the event of nondisclosure, a unique number will be assigned to your file.

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

FAA Form 8710-11 (02-04)

Form Approved OMB No: 2120-0690

8/31/2015

Airman Certificate and/or Rating Application – Sport Pilot

U.S. Department of Transportation

Federal Aviation Administration

4. Ratings

III. Record of Pilot Time (Do not write in the shaded areas)

V.Applicant’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.

Instructor’s Recommendation

Air Agency’s Recommendation

Title

Designated Examiner or Airman Certification Representative Report

Proficiency Check – Instructor’s Record

I have successfully reviewed this applicants pilot logbook and/or training record and certify the individual meets the pertinent requirements of 14 CFR part 61 (Subparts K {61.419} or J{61.321} for the proficiency check sought.

I have personally tested this applicant in accordance with the pertinent procedures and standards of 14 CFR pert 61 (Subparts K or J), and find the applicant proficient

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, standards, policies, and or necessary requirements with the result indicated below.