Form 8710 10 – Fill Out and Use This PDF

NATIONAL EXAMINER BOARD DESIGNATED PILOT EXAMINER CANDIDATE

APPLICATION

PRIVACY ACT STATEMENT: This statement is provided pursuant to the Privacy Act of 1974, 5 USC § 552a:

The authority for collecting this information is contained in 49 U.S.C. §§ 40113, 44702, 44703, 44709 and 14 C.F.R. Part 6 1. 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. Submission of the data is mandatory, except for the Social Security Number, which is voluntary. Failure to provide all required information will result in our being unable to issue you a certificate and/or rating. The information collected on this form will be included in a Privacy Act System of Records known as DOT/FAA 847, 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.dot.gov/privacy/privacyactnotices), including:

(a)Providing basic airmen certification and qualification information to the public upon request; examples of basic information include:

•The type of certificates and ratings held, limitations, date of issuance and certificate number;

•The status of the airman’s certificate (i.e., whether it is current or has been amended, modified, suspended or revoked for any reason); The airman’s home address, unless requested by the airman to be withheld from public disclosure per 49 U.S.C. 44703(c);

•Information relating to an airman’s physical status or condition used to determine statistically the validity of FAA medical standards; and the date, class, and restrictions of the latest physical

•Information relating to an individual’s eligibility for medical certification, requests for exemption from medical requirements, and requests for review of certificate denials.

(b)Using contact information to inform airmen of meetings and seminars conducted by the FAA regarding aviation safety.

(c)Disclosing information to the National Transportation Safety Board (NTSB) in connection with its investigation responsibilities.

(d)Providing information about airmen to Federal, State, local and tribal law enforcement agencies when engaged in an official investigation in which an airman is involved.

(e)Providing information about enforcement actions, or orders issued thereunder, to Federal agencies, the aviation industry, and the public upon request.

(f)Making records of delinquent civil penalties owed to the FAA available to the U.S. Department of the Treasury and the U.S. Department of Justice (DOJ) for collection pursuant to 31 U.S.C. 3711(g).

(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.

(g)Making airmen records available to users of FAA’s Safety Performance Analysis System (SPAS), 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, targeting inspection efforts for certificate holders of greatest risk, and monitoring the effectiveness of targeted oversight actions.

(h)Making records of an individual’s positive drug test result, alcohol test result of 0.04 or greater breath alcohol concentration, or refusal to submit to testing required under a DOT-required testing program, available to third parties, including current and prospective employers of such individuals. Such records also contain the names and titles of individuals who, in their commercial capacity, administer the drug and alcohol testing programs of aviation entities.

(i)Providing information about airmen through the Civil Aviation Registry’s Comprehensive Airmen Information System to the Department of Health and Human Services, Office of Child Support Enforcement, and the Federal Parent Locator Service that locates noncustodial parents who owe child support. Records in this system are used to identify airmen to the child support agencies nationwide in enforcing child support

obligations, establishing paternity, establishing, and modifying support orders and location of obligors. Records listed within the section on Categories of Records are retrieved using Connect: Direct through the Social Security Administration’s secure environment.

(j)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.

(k)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.

(l)Making airman, aircraft, and operator record elements available to users of FAA’s Skywatch system, including the Department of Defense (DoD), the Department of Homeland Security (DHS), DOJ and other authorized Federal agencies, for their use in managing, tracking and reporting aviation-related security events. Other possible routine uses published in the Federal Register (see Prefatory Statement of General Routine Uses for additional uses (65 F.R. 19477-78) For example, 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, TSA or Coast Guard function related to this system of records.

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Supplemental Information and Instructions (Continued)

TYPES OF DESIGNATIONS AND DESIGNEE DEFINITIONS—

PE	-	Private Pilot Examiner
CIRE	- Commercial and Instrument Rating Pilot Examiner
CE	- Commercial Pilot Examiner (For rotorcraft, gliders, and/or lighter-than-air aircraft only.)
ATPE	-	Airline Transport Pilot Examiner

GENERAL QUALIFICATIONS—

•The applicant must hold all pertinent category, class, and type ratings for each aircraft for which designation is sought.

•For a designation requiring a medical certificate, the applicant must hold a valid third-class airman medical certificate for initial designation. (A medical certificate is NOT required for designations limited to examining in balloons and gliders.)

•The applicant must be at least 21 years old.

•The applicant must have a good record as a pilot and flight instructor with regard to accidents, incidents, and violations.

•The applicant must meet all eligibility and experience requirements for the specific designation sought in accordance with the tables beginning on page iv for PE, CE, CIRE, ATPE requirements, the appropriate FAA order, handbooks, and pertinent, current Flight Standards Handbook Bulletin for General Aviation.

•The applicant must have a reputation for integrity and dependability in the industry and the community.

•The applicant must have a history of a harmonious relationship with the FAA.

INSTRUCTIONS FOR COMPLETING FAA FORM 8710-10—

1.All entries on FAA Form 8710-10 must be made in black ink or typewritten.

2.Read the attached "Privacy Act Statement."

3.Complete blocks 1 through 33:

a.Block 1. Name (Last, First, Middle)—

(1)Enter your legal name. For record purposes, do not use more than one middle name.

(2)If you do not have a middle name, enter "NMN" (no middle name) or "NMI" (no middle initial).

(3)If you have initial(s) only, enter the initials and then enter "INITIALS ONLY."

(4)If you are a junior, III, IV, etc., so indicate.

b.Block 2. Social Security Number—

(1)Completing Block 2 is optional (see "Privacy Act Statement").

(2)Enter your Social Security Number or one of the following: "DO NOT USE" or "NONE."

c.Block 2A. Date of Birth—Enter date using eight-digit, numeric characters (e.g., 08/09/1960 not August 9, 1960).

d.Block 3. Permanent Mailing Address—Enter all required information, to include number and street, P.O. Box, City, State, and Zip Code.

e.Block 4. Telephone Number—Enter your home and business telephone numbers including the area code and extensions, if applicable.

You may also enter your Fax number, if applicable.

f.Block 5. This application is for:—Initial Application for NEB, Renewal Application for NEB, or Reinstatement (other than initial

designating FSDO) for NEB. Check the box to the left of the reason for this application. NOTE: Reinstatements are NOT to be sent to the NEB unless the applicant has moved to a different district.

g.Block 6. Have you ever held an FAA pilot examiner designation in any region?—(If "YES," enter the date(s) and the supervising FSDO.)

h.Block 7. Type of designation(s) sought:—Check the box to the left of the designation(s) sought. Private Pilot Examiner (PE),

Commercial Pilot Examiner (CE), Airline Transport Pilot Examiner (ATPE), and Commercial Instrument Rating Examiner (CIRE). (See the SPECIFIC ELIGIBILITY REQUIREMENTS criteria shown on pages iv and v.)

i.Block 8. Enter the categories, classes, and types of aircraft for which authorization is sought.—Self-explanatory.

j.Block 9. Enter the FSDO that has jurisdiction in the area where you desire to serve.—Self-explanatory.

k.Block 10. Enter the names of other FSDO's in whose areas you can provide examiner service on a regular basis, if any.—Self- explanatory.

l.Block 11. Has any certificate or rating issued to you ever been revoked?—(If "YES," describe the circumstances.)

m.Block 12. Have you had any aircraft accidents or incidents within the past 5 years?—(If "YES," describe the circumstances.)

n.Block 13. Are you a U.S. citizen?—(You must enter "YES" or "NO.") NOTE: You are not required to be a U.S. citizen in order to be a designated examiner.

o.Block 14. If you are NOT a U.S. citizen, enter the country in which you hold citizenship. If you hold dual citizenship, indicate the names of both countries.—Self-explanatory.

p.Block 15. Do you read, write, speak, and understand English fluently?—Self-explanatory.

q.Block 16. FAA certificates held—Enter all certificates held, their certificate numbers, and their ratings and limitations as shown on the certificate. NOTE: You must provide copies (front and back) of all certificates.

r.Block 17. Enter all of your special training which is pertinent to the designation sought.—Self-explanatory.

s.Block 18A. Have you ever served as a chief or assistant chief instructor in a school authorized under Title 14 of the Code of Federal Regulations (14 CFR) part 141?—(If "YES," enter the date(s).)

t.Block 18B. Have you ever served as a check airman authorized under Title 14 of the Code of Federal Regulations (14 CFR) part 121 and/or part 135?—(If "YES," enter the date(s) and the FSDO.)

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Supplemental Information and Instructions (Continued)

u.Block 18C. Have you ever been an FAA Aviation Safety Inspector?—(If "YES," enter the date(s) and the FSDO.)

v.Block 19. Have you ever been a military pilot evaluator?—(If "YES," enter the date(s).)

w.Block 20. Have you ever been an FAA Accident Prevention Counselor or FAA Aviation Safety Counselor?—(If "YES," enter the date(s) and the FSDO.)

x.Block 21. Flight Experience—Enter all your actual flight time (in hours), as requested. Do not round off or approximate your hours (i.e.,

± ). Do not write in the shaded areas. Answer Blocks 21A through 21I, if applicable. NOTE: Total flight instruction given and/or instrument flight instruction given. (See the SPECIFIC ELIGIBILITY REQUIREMENTS criteria shown on pages iv and v.)

y.Block 22. Work Experience—Describe your current or most recent work experience in Block 22A and work backwards. Use a separate block for each position described (e.g., Block 22A, Block 22B, etc.). Describe all of your work experience in specific detail that pertains

to your qualifications for the designation(s) sought. Describe each applicable position you held during at least the past 5 years. You may describe work experience accrued more than 5 years ago. Include military service if your military experience is pertinent to your application for an examiner designation.

(1)Complete the name, address, and telephone number of the employer/organization.

(2)Job Title: Self-explanatory.

(3)Dates Employed: Enter the dates of employment.

(4)Supervisor's Name: Self-explanatory.

(5)Reason for Leaving: Self-explanatory.

(6)Description of Duties: Enter a complete description of the duties performed during this period of employment.

z.Block 23. Briefly summarize your aviation activities and professional responsibilities that best qualify you to be a designated pilot examiner.—Self-explanatory.

aa.Block 24. During the past 5 years, were you fired from any job for any reason?—NOTE: If you answer "YES," you MUST enter the full details in Block 31.

bb.Block 25. Have you ever been convicted of any felony violation?—NOTE: If you answer "YES," you MUST enter the full details in

Block 31.

cc.Block 26. Are you now under charges for any violation of law?—NOTE: If you answer "YES," you MUST enter the full details in

Block 31.

dd.Block 27. Have you ever been imprisoned, been on probation, or been on parole?—NOTE: If you answer "YES," you MUST enter the full details in Block 31.

ee.Block 28. Have you ever been convicted by a military court-martial?—NOTE: If you answer "YES," you MUST enter the full details in

Block 31.

ff.Block 29. Have you ever been discharged from a military service under a General discharge?—NOTE: If you answer "YES," you

MUST enter the full details in Block 31.

gg.Block 30. Have you ever been discharged from a military service under other than honorable conditions?—NOTE: If you answer "YES," you MUST enter the full details in Block 31.

hh.Block 31. If you answered "YES" to any questions in Blocks 24 through 30, you MUST enter the full details.

ii.Block 32. Education and Training—Are you a high school graduate? (If "YES," enter the name of the high school and the date you graduated.) Are you a GED graduate? (If "YES," enter the date you received the GED.)

(1)College and/or Technical Training Dates: Enter the beginning and ending dates of the training that you attended.

(2)Name of School: Enter the name of the school(s) you attended.

(3)Curriculum or Study Program: Enter the curriculum or study program for each school(s) listed.

(4)Degree or Certificate Received: Enter degrees or certificates you received from each school(s) listed.

jj.Block 33. Applicant's Signature—After you read the "RELEASE OF INFORMATION AND CERTIFICATION STATEMENT" and the "NOTICE," sign the application, in black ink. After you sign your name, print or type your name under your signature. Enter the date you signed the application using eight-digit, numeric characters (e.g., 08/09/1999 not August 9, 1999).

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Supplemental Information and Instructions (Continued)

LIST OF FLIGHT STANDARDS DISTRICT OFFICES

ALASKAN REGION (AAL)		GREAT LAKES REGION (AGL)		SOUTHERN REGION (ASO)		WESTERN PACIFIC REGION (AWP)
ANC FSDO-03	ANCHORAGE, AK	CLE FSDO-25	CLEVELAND, OH	ATL FSDO-11	COLLEGE PARK/	FAT FSDO-17	FRESNO, CA
FAI FSDO-01	FAIRBANKS, AK	CMH FSDO-07	COLUMBUS, OH		ATLANTA, GA	HNL FSDO-13	HONOLULU, HI
JNU FSDO-05	JUNEAU, AK	CVG FSDO-05	CINCINNATI, OH	BHM FSDO-09	BIRMINGHAM, AL	LAS FSDO-19	LAS VEGAS, NV
CENTRAL REGION (ACE)		DPA FSDO-03	WEST CHICAGO,	BNA FSDO-03	NASHVILLE, TN	LAX FSDO-23	LOS ANGELES, CA
			IL	CAE FSDO-13	WEST COLUMBIA, SC	LGB FSDO-05	LONG BEACH, CA
DSM FSDO-01	DES MOINES, IA	DTW FSDO-23	BELLEVILLE, MI	FLL FSDO-17	FT. LAUDERDALE, FL	OAK FSDO-27	OAKLAND, CA
ICT FSDO-07	WICHITA, KS	FAR FSDO-21	FARGO, ND	TPA-FSDO-35	TAMPA, FL	RAL FSDO-21	RIVERSIDE, CA
LNK FSDO-09	LINCOLN, NE	GRR FSDO-09	GRAND RAPIDS,	INT FSDO-05	WINSTON-SALEM, NC	RNO FSDO-11	RENO, NV
MCI FSDO-05	KANSAS CITY, MO		MI	JAN FSDO-07	JACKSON, MS	SAC FSDO-25	SACRAMENTO, CA
STL FSDO-03	ST. ANN/	IND FSDO-11	INDIANAPOLIS, IN	LOU FSDO-01	LOUISVILLE, KY	SAN FSDO-09	SAN DIEGO, CA
	ST. LOUIS, MO	MKE FSDO-13	MILWAUKEE, WI	MEM FSDO-25	MEMPHIS, TN	SDL FSDO-07	SCOTTSDALE, AZ
EASTERN REGION (AEA)		MSP FSDO-15	MINNEAPOLIS,	MIA FSDO-19	MIAMI, FL	SJC FSDO-15	SAN JOSE, CA
			MN	ORL FSDO-15	ORLANDO, FL	VNY FSDO-01	VAN NUYS, CA
ABE FSDO-05	ALLENTOWN, PA	ORD FSDO-31	SCHILLER PARK,	CLT FSDO-33	CHARLOTTE, NC	SFO FSDO-03	SAN FRANCISCO,
FRG FSDO-11	FARMINGDALE,		IL	SJU FSDO-21	SAN JUAN, PR		CA
	NY	RAP FSDO-27	RAPID CITY, SD	TPA FSDO	TAMPA, FL
AGC FSDO-03	W. MIFFLIN/	SBN FSDO-17	SOUTH BEND, IN			INTERNATIONAL FIELD OFFICE
	PITTSBURGH, PA	SPI FSDO-19	SPRINGFIELD, IL	SOUTHWEST REGION (ASW)			LIST
ALB FSDO-01	ALBANY, NY			ABQ FSDO-01	ALBUQUERQUE, NM	FRA IFO-EA33	FRANKFURT
BAL FSDO-07	BALTIMORE, MD	NEW ENGLAND REGION (ANE)		BTR FSDO-03	BATON ROUGE, LA	SIN IFO-WP33	SINGAPORE
CRW FSDO-09	CHARLESTON, WV	BED FSDO-01	BEDFORD, MA	DAL FSDO-05	DALLAS, TX	BRX IFO-EA31	BRUSSELS
DCA FSDO-27	CHANTILLY, VA	BDL FSDO-03	WINDSOR LOCKS,	DFW FSDO-07	DALLAS, TX	LGW IFO-EA35	LONDON
	WASH, DC		CT	FTW FSDO-19	FT. WORTH, TX	MIA IFO-SO23	MIAMI SPNGS, FL
HAR FSDO-13	NEW	BOS FSDO-02	BOSTON, MA	HOU FSDO-09	HOUSTON, TX	DFW IFO-SW23	DALLAS, TX
	CUMBERLAND/	PWM FSDO-05	PORTLAND, ME	LBB FSDO-13	LUBBOCK, TX
	HARRISBURG, PA			LIT FSDO-11	LITTLE ROCK, AR
PHL FSDO-17	PHILADELPHIA,PA	NORTHWEST MOUNTAIN		OKC FSDO-15	OKLA. CITY, OK
NYC FSDO-15	GARDEN CITY, NY	REGION (ANM)		SAT FSDO-17	SAN ANTONIO, TX
PIT FSDO-19	CORAOPOLIS/	BOI FSDO-11	BOISE, ID
	PITTSBURGH, PA	CPR FSDO-04	CASPER, WY
RIC FSDO-21	SANDSTON/	DEN FSDO-03	DENVER, CO
	RICHMOND, VA	GEG FSDO-13	SPOKANE, WA
ROC FSDO-23	ROCHESTER, NY	HLN FSDO-05	HELENA, MT
TEB FSDO-25	TETERBORO, NJ	PDX FSDO-09	HILLSBORO/
NY IFO-29	JAMAICA, NY		PORTLAND, OR
		SEA FSDO-01	SEATTLE, WA
		SLC FSDO-07	SALT LAKE CITY,
			UT
		DEN FSDO-30	DENVER, CO

SPECIFIC ELIGIBILITY REQUIREMENTS FOR

PRIVATE PILOT EXAMINER (PE) DESIGNEES

ELIGIBILITY
REQUIREMENTS	AIRPLANE	ROTORCRAFT	GLIDERS	L-T-A AIRSHIPS	L-T-A BALLOON
CERTIFICATES	Commercial Pilot	Commercial Pilot	Commercial Pilot	Commercial Pilot	Commercial Pilot
REQUIRED	Flight Instructor	Flight Instructor	Flight Instructor
CERTIFICATE	Both with Airplane	Both with Rotorcraft category	Both with Glider	Lighter Than Air	Lighter Than Air
CATEGORIES	category		category
RATINGS	Both with appropriate	Helicopter or Gyroplane class		Airship class rating	Balloon class rating
	airplane class rating(s)	rating(s), as appropriate
	Instrument-Airplane on
	pilot certificate only
HOURS AS PIC	2,000	1,000	500	1,000	200
	• 1,000 in airplanes that	• 500 in rotorcraft that	• 200 in gliders	• 500 in airships that	• 100 in balloons that
	include 300 in past	include at least 100	that include 10	include at least 200 in	include 20 hours in past
	year	in past year	hours in past	past year	year of at least 10 flights
	• 300 in airplane class	• 250 in helicopters or 150 in	year of at least	• 50 at night	each of at least 30
	• 100 at night	gyroplanes, as appropriate	10 flights		minutes duration
HOURS AS FLIGHT	500 in airplanes	200 in helicopters or	100 in gliders	100 in airships	50 in balloons
INSTRUCTOR (as a CFI	• 100 in class	gyroplanes, as appropriate			• 10 in past year
or as a Military Flight
Instructor)

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Supplemental Information and Instructions (Continued)

SPECIFIC ELIGIBILITY REQUIREMENTS FOR

COMMERCIAL PILOT EXAMINER (CE) DESIGNEES

ELIGIBILITY		ROTORCRAFT
REQUIREMENTS	AIRPLANE	(VFR ONLY)	GLIDERS	L-T-A AIRSHIPS	L-T-A BALLOON
CERTIFICATES REQUIRED		Commercial Pilot Flight	Commercial Pilot	Commercial Pilot	Commercial Pilot
		Instructor	Flight Instructor
CERTIFICATE		Both with Rotorcraft category	Both with Glider	Lighter-Than-Air	Lighter-Than-Air
CATEGORIES			category
RATINGS		Helicopter or Gyroplane class		Airship class rating	Balloon class rating
		rating(s), as appropriate
HOURS AS PIC		2,000	500	2,000	200
		• 500 in rotorcraft that	• 250 in gliders that	• 500 in airships that	• 100 in balloons that
		include at least 100 in past	include at least 20	include at least 200	include at least 20
		year	hours in the past	in past year	hours in past year of
		• 250 in helicopters or 150 in	year of at least 50	• 50 at night	at least 10 flights
		gyroplanes, as appropriate.	flights		each of at least 30
		• If applicable, 100 in large			minutes duration
		helicopters that include 50 in			• Held a Commercial
		the type helicopter sought,			Pilot Certificate-
		and 25 in each additional			Balloon for at least 1
		type sought			year
HOURS AS FLIGHT		200 in helicopters or	200	100 in airships	50 in balloons
INSTRUCTOR (as a CFI or		gyroplanes, as appropriate.	• 100 in gliders		• 10 in the past year
as a Military Flight Instructor)		• 50 in helicopters or
		gyroplanes, as appropriate,
		preparing pilots for a
		Commercial Pilot Certificate

SPECIFIC ELIGIBILITY REQUIREMENTS FOR

COMMERCIAL AND INSTRUMENT RATING EXAMINER (CIRE) AND

AIRLINE TRANSPORT PILOT EXAMINER (ATPE) DESIGNEES

	TYPE OF CIRE DESIGNATION		TYPE OF ATPE DESIGNATION
ELIGIBILITY	AIRPLANE &	HELICOPTER &	AIRPLANE	HELICOPTER
REQUIREMENTS	INSTRUMENT	INSTRUMENT
CERTIFICATES	Commercial Pilot Flight	Commercial Pilot Flight	Airline Transport Pilot	Airline Transport Pilot
REQUIRED	Instructor	Instructor	Flight Instructor	Flight Instructor
CERTIFICATE	Both with Airplane	Both with Rotorcraft category	Both with Airplane category	Both with Rotorcraft category
CATEGORIES	category
RATINGS	Both with appropriate	Helicopter class rating;	Both with appropriate	Both with Helicopter rating and
	airplane class ratings and	Instrument-Helicopter	airplane class rating(s) and	instrument privileges on ATP and
	Instrument-Airplane		instrument privileges on	Instrument-Helicopter on CFI
			ATP and Instrument-
			Airplane on CFI
HOURS AS PIC	2,000	2,000	2,000	2,000
	• 1,000 in airplanes that	• 500 in helicopters that include	• 1,500 in airplanes, that	• 1200 in helicopters, that include 100
	include 300 in airplanes in	100 in helicopters in past year	include 300 in airplanes in	in helicopters in past year
	past year	• 100 instrument flight (actual	past year	• 100 instrument flight (actual or
	• 500 in class of airplane	or simulated)	• 500 in class airplane	simulated)
	• 100 at night in airplanes	• If applicable, 100 in large	• 100 at night in airplanes	• If applicable, 100 in large
	• 200 in complex airplanes	helicopters, that include 50 in	• 200 complex airplanes	helicopters, that include 50 in type
	• 100 instrument flight	type sought and 25 in each	• 100 instrument flight	sought and 25 in each additional type
	(actual or simulated)	additional type sought	(actual or simulated)	sought
	• If applicable, 300 in large		• If applicable, 300 in large
	or turbine-power airplanes,		or turbine-power airplanes,
	that include 50 in type		that include 50 in type
	sought and 25 in each		sought and 25 in each
	additional type sought		additional type sought
HOURS AS FLIGHT	500 in airplanes	250 in helicopters	500 in airplanes	250 in helicopters
INSTRUCTOR (as a CFI	• 100 in class of airplane	• 50 instrument flight	• 100 in class of airplane	• 50 of instrument flight instruction in
or as a Military Flight	• 250 instrument flight	instruction in helicopters	• 250 instrument flight	helicopters
Instructor)	instructor time, that	• 100 preparing pilots for	instructor time, that include	• 100 in helicopters preparing pilots
	includes 200 in airplanes	Commercial Pilot-Helicopter	200 in airplanes	for Commercial Pilot Certificate or
			• 150 preparing pilots for	ATP Certificate with a Helicopter
			Commercial Pilot or ATP	class or type rating or Instrument-
			with airplane category or	Helicopter rating
			type rating or Instrument-
			Airplane rating

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U.S. Department of Transportation

Federal Aviation Administration

1. Name (Last, First, Middle)—

2. Social Security Number—

2A. Date of Birth—

-

-

3. Permanent Mailing Address—

4.

Telephone Numbers—

Home Phone: (

)

City:

State:

Zip Code:

Business Phone: (

)

Fax Number: (

)

5.

This application is for:—

6. Have you ever held an FAA pilot examiner

7.

Type of designation(s) sought:—

designation in any region?—

Initial Application for NEB

(If "Yes," enter the date(s) and the supervising

PE

FSDO.)

Renewal Application for NEB

CE

YES

NO

Reinstatement (other than initial

ATPE

From (mo/yr):____________

designating FSDO) for NEB

CIRE

To (mo/yr):______________

FSDO:__________________

8.

Enter the categories, classes, and types of

9. Enter the FSDO that has jurisdiction in the

10.

Enter the names of other FSDO's in whose areas you can

aircraft for which authorization is sought.—

area where you desire to serve.—

provide examiner service on a regular basis, if any.—

_____________________________________

____________________________________

______________________________________________

_____________________________________

____________________________________

______________________________________________

_____________________________________

____________________________________

______________________________________________

_____________________________________

____________________________________

______________________________________________

11.Has any certificate or rating issued to you ever been revoked?—12. Have you had any aircraft accidents or incidents within the past 5 years?—

(If "YES," describe the circumstances.)

(If "YES," describe the circumstances.)

NO

YES

NO

YES

__________________________________________________________

_______________________________________________________________

__________________________________________________________

_______________________________________________________________

__________________________________________________________

_______________________________________________________________

__________________________________________________________

_______________________________________________________________

__________________________________________________________

_______________________________________________________________

13. Are you a U.S. citizen?—

14. If you are NOT a U.S. citizen, enter the

15. Do you read, write, speak, and understand English

country in which you hold citizenship. If you

fluently?—

hold dual citizenship, indicate the names of

YES

NO

both countries.—

YES

NO

____________________________________

16.FAA certificates held—You MUST provide copies (front and back) of all certificates.

Type of Certificate	Certificate Number	Ratings and Limitations (as shown on the certificate)
_______________________________________	______________________________________	_________________________________________________
_______________________________________	______________________________________	_________________________________________________
_______________________________________	______________________________________	_________________________________________________

17.Enter all of your special training which is pertinent to the designation sought.—

__________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________

18A. Have you ever served as a chief or assistant chief instructor in a school authorized under Title 14 of the Code of Federal Regulations (14 CFR) part 141?—

(If "YES," enter the date(s).)

YES

NO

From (mo/yr):_____________ To (mo/yr):_____________

18B. Have you ever served as a check airman authorized under Title 14 of the Code of Federal Regulations (14 CFR) part 121 and/or part 135?—

(If "YES," enter the date(s) and the FSDO.)

YES

NO

From (mo/yr):_____________ To (mo/yr):_____________

FSDO:____________________________________

18C. Have you ever been an FAA Aviation Safety Inspector?—(If "YES," enter the date(s) and the FSDO.)

YES

NO

From (mo/yr):_____________ To (mo/yr):_____________FSDO:_________________________________________

19.Have you ever been a military pilot evaluator?—(If "YES," enter the date(s).)

YES

NO

From (mo/yr):_____________ To (mo/yr):_____________

20.Have you been an FAA Accident Prevention Counselor or FAA Aviation Safety Counselor?—(If "YES," enter the date(s) and the FSDO.)

21B. Enter number of glider flights as PIC within the past year.—______________________________________________________________________________

21C. Enter number of balloon flights as PIC that were at least 30 minutes duration within the past year.—______________________________________________

21D. Enter number of hours as PIC in complex airplanes.—___________________________________________________________________________________

21E. Enter number of hours flight instruction given in rotorcraft preparing pilots for commercial pilot certificate.—__________________

21F. Enter date your commercial balloon certificate was acquired.—____________________________________________________________________________

21G. Enter number of hours flight instruction given in airplanes preparing pilots for an ATP certificate, an instrument rating, or a type rating.—________________

21H. Enter number of hours flight instruction given in helicopters preparing pilots for an ATP certificate, an instrument rating, or a type rating.—_______________

21I. Enter number of pilot and/or flight instructor certification practical tests completed within the past year (as FAA Aviation Safety Inspector).—_____________

22.Work Experience—Describe your current or most recent work experience in Block 22A and work backwards. Use a separate block for each position described (e.g., Block 22A, Block 22B, etc.). Describe all of your work experience in specific detail that pertains to your qualifications for the designation(s) sought. Describe each applicable position you held during at least the past 5 years. You may describe work experience accrued more than 5 years ago. Include military service if your military experience is pertinent to your application for an examiner designation.

22A. Name of Employer/Organization:			Telephone
			Number (	)
Address:
City:		State:		Zip Code:
Job Title:	Dates Employed (mo/yr):		Supervisor's Name:
	From:	To:
Reason for Leaving:
Description of Duties:

22B. Name of Employer/Organization:			Telephone
			Number (	)
Address:
City:		State:		Zip Code:
Job Title:	Dates Employed (mo/yr):		Supervisor's Name:
	From:	To:
Reason for Leaving:
Description of Duties:

22C. Name of Employer/Organization:	Telephone
	Number (	)
Address:
City:	State:	Zip Code:

FAA Form 8710-10 (1/00) SUPERSEDES PREVIOUS EDITION

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Job Title:	Dates Employed	(mo/yr):		Supervisor's Name:
	From:	To:
Reason for Leaving:
Description of Duties:
22D. Name of Employer/Organization:				Telephone
				Number	(	)
Address:
City:			State:			Zip Code:
Job Title:	Dates Employed	(mo/yr):		Supervisor's Name:
	From:	To:
Reason for Leaving:
Description of Duties:
22E. Name of Employer/Organization:				Telephone
				Number	(	)
Address:
City:			State:			Zip Code:
Job Title:	Dates Employed	(mo/yr):		Supervisor's Name:
	From:	To:
Reason for Leaving:
Description of Duties:
22F. Name of Employer/Organization:				Telephone
				Number	(	)
Address:
City:			State:			Zip Code:
Job Title:	Dates Employed	(mo/yr):		Supervisor's Name:
	From:	To:
Reason for Leaving:
Description of Duties:

FAA Form 8710-10 (1/00) SUPERSEDES PREVIOUS EDITION

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23.Briefly summarize your aviation activities and professional responsibilities that best qualify you to be a designated pilot examiner.—

________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________

24.

During the past 5 years, were you

25. Have you ever been convicted of

26.

Are you now under charges for

27.

Have you ever been imprisoned,

fired from any job for any reason?—

any felony violation?—

any

violation of law?—

been on probation, or been on

YES

NO

YES

NO

YES

NO

parole?—

NO

YES

28.

Have you ever been convicted by a

military

29.

Have you ever been

discharged from a military

30. Have you ever

been discharged

from a military

court

-martial?—

service

under a

General discharge?—

service

under other than honorable conditions?—

YES

NO

YES

NO

YES

NO

31.If you answered "YES" to any questions in Blocks 24 through 30, you MUST enter the full details.

_________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________

32.Education and Training—

Are you a high school graduate?				YES			NO	Name of High School:_______________________________Date Graduated (mo/yr):______________
Are you a GED graduate?				YES			NO	Date received GED (mo/yr):__________________________
College and/or Technical Training Dates:								Name of School:	Curriculum or Study Program:	Degree or Certificate Received:
From (mo/yr):		To (mo/yr):

RELEASE OF INFORMATION AND CERTIFICATION STATEMENT—

Read this statement CAREFULLY.

After you read this statement, you MUST sign and date this application in black ink.

Under your signature, you MUST print or type your name.

¸I understand that a false statement on any part of this application will be grounds for not approving this application, for rescinding my eligibility as an examiner candidate, for not designating me, or terminating any designation I may receive.

¸I understand that any information given may be investigated.

¸I consent to the release of information regarding my personal and technical qualifications for designation as a pilot examiner by employers, schools, law enforcement agencies, and other individuals and organizations, to investigators, employees of the Federal government, and persons not employed by the Federal government to whom the FAA has delegated the authority to screen and approve or disapprove pilot examiner applicants.

¸I understand that assignment to the national examiner candidate pool does not guarantee selection or designation as a pilot examiner and that, if selected, designation is dependent on satisfactory completion of a practical test (demonstration of competency) and satisfactory completion of the Initial Pilot Examiner Standardization Seminar.

¸I understand that my FAA accident/incident/violation history will be verified at each stage of the application process.

¸I understand that designation as a pilot examiner is a privilege, not a right, and that any designation received may be terminated, revoked, or not renewed at any time for any reason the FAA Administrator deems appropriate.

¸I certify that, to the best of my knowledge and belief, all of my statements on this application are true, correct, complete, and made in good faith.

FAA Form 8710-10 (1/00) SUPERSEDES PREVIOUS EDITION

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FAA Form 8710-10 (1/00) SUPERSEDES PREVIOUS EDITION

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FOR NATIONAL EXAMINER BOARD USE ONLY

(For Original Issuance Only)
		Accepted for Predesignation Testing					Not Qualified	Date:_________________________
		Predesignation Test Score:____________________						Date of Test:___________________
		Approved for Pool			Disapproved for Pool			Date:___________________

Signature of NEB Official:___________________________________________ Title:______________________________________

Referred to:_____________________FSDO								Date:___________________
		Selected						Date:___________________
				Declined
FOR FSDO USE ONLY: FAA Form 8710-6 may be used for renewals, additional authorizations, and/or reinstatements.
Inspector's Recommendation:								Disapprove
						Approve
Reason for Disapproval (Attach additional sheets, if required.):

The individual submitting this application has satisfactorily demonstrated competency to perform the duties of the following designation(s):

PE

CE

CIRE

ATPE

FIE (Must have 1 year as CE/CIRE.)

Aircraft

Categories:

Airplane

Rotorcraft

Glider

Lighter-Than-Air

Additional Qualifications/Limitations (if any):

Inspector's

Signature:_________________________________________________ Date: ________________________ FSDO:_____________________

Regional Office:
		Approve			Disapprove			Date:		_____________________
Signature: ____________________________________________________________________								Routing Symbol:	_____________________
FSDO:
	Certificate of Authority Issued:					Date: ___________________________		FSDO:	______________________
Examiner Number: _______________________________________________								Expiration Date: ______________________
LOA(s) Issued:
_______________			_______________			________________	_________________	_________________		_________________

Additional FSDO's to be served by the examiner (if any):

FAA Form 8710-10 (1/00) SUPERSEDES PREVIOUS EDITION

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