8610-2 Airman Certificate and/or Rating Application

AIRMAN CERTIFICATE AND/OR RATING 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 5. 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.
(h) 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.
(i) 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.
(j) 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.
(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.
(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.
(m) 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.
(n) 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.

FAA Form 8610-2 (2-85)

TEAR OFF
BEFORE USE

U.S. Department of Transportation
Federal Aviation Administration

SUPPLEMENTAL
INFORMATION

Paperwork Reduction Act Statement: The information collected on this form is necessary to ensure applicant eligibility. The information is used to
determine that the applicant meets the necessary qualifications as a Mechanic, Repairman, or Parachute Rigger. We estimate that it will take
approximately 20 minutes to complete the form. The information collection is required to obtain a benefit. The information collected becomes part of
the Privacy Act system of records DOT/FAA 847, Aviation Records on Individuals. Please not 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 2120-0022. 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, ABA-20.

FAA Form 8610-2 (2-85)

Electronic Version (Adobe)

Form Approved
OMB. No. 2120-0022 2/28/2011

TYPE OR PRINT ALL ENTRIES IN INK
U.S. Department of Transportation
Federal Aviation Administration

AIRMAN CERTIFICATE AND/OR RATING APPLICATION
REPAIRMAN
MECHANIC
MECHANIC
AIRFRAME
AIRFRAME
POWERPLANT
POWERPLANT
APPLICATION FOR:

REPAIRMAN

PARACHUTE
RIGGER RIGGER
PARACHUTE
SENIORSENIOR
(Specify Rating)

ORIGINAL ISSUANCE

'

ADDED RATING

CHEST
CHEST

BACK
BACK

LAP
LAP

K. PERMANENT MAILING ADDRESS

A. NAME (First, Middle, Last)

I. APPLICANT INFORMATION

MASTER
MASTER

SEAT
SEAT

B. SOCIAL SECURITY NO.

C. DOB (Mo., Day., Yr.)

D. HEIGHT

E. WEIGHT

NUMBER AND STREET, P.O. BOX, ETC.

IN.
F. HAIR

G. EYES

H. SEX

I. NATIONALITY (Citizenship)
CITY

J. PLACE OF BIRTH
STATE
ZIP CODE
M. DO YOU NOW OR HAVE YOU EVER HELD AN FAA AIRMAN
CERTIFICATE?
NO
YES

L. HAVE YOU EVER HAD AN AIRMAN CERTIFICATE SUSPENDED OR REVOKED?
NO

SPECIFY TYPE:

YES (If "Yes," explain on an attached sheet keying to appropriate item number).
N. HAVE YOU EVER BEEN CONVICTED FOR VIOLATION OF ANY FEDERAL OR STATE STATUTES
PERTAINING TO NARCOTIC DRUGS, MARIJUANA, AND DEPRESSANT OR STIMULANT
DRUGS OR SUBSTANCES? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
B. MILITARY
EXPERIENCE

A. CIVIL
EXPERIENCE

II. CERTIFICATE OR
RATING APPLIED FOR
ON BASIS OF -

DATE OF FINAL CONVICTION
NO

YES
C. LETTER OF RECOMMENDATION FOR
REPAIRMAN (Attach copy)

(1) NAME AND LOCATION OF SCHOOL
D. GRADUATE
OF APPROVED
COURSE

(2) SCHOOL NO.

(3) CURRICULUM FROM WHICH GRADUATED

E. STUDENT HAS MADE SATISFACTORY PROGRESS
AND IS RECOMMENDED TO TAKE THE ORAL/
PRACTICAL TEST (FAR 65.80)

(1) SCHOOL NAME

(1) SERVICE

A. MILITARY
COMPETANCE
OBTAINED IN

NO.

(2) SCHOOL OFFICIAL'S SIGNATURE

(2) DATE AUTH. EXPIRES (3) FAA INSPECTOR SIGNATURE

(1) DATE AUTH.

F. SPECIAL AUTHORIZATION TO TAKE
MECHANIC'S ORAL/PRACTICAL TEST
(FAR 65.80)

(4) DATE

(2) RANK OR PAY LEVEL

(4) FAA DIST OFC.

(3) MILITARY SPECIALITY CODE

III. RECORD OF EXPERIENCE

B. APPLICANT'S OTHER THAN FAA CERTIFICATED SCHOOL GRADUATES. LIST EXPERIENCE RELATING TO CERTIFICATE AND RATING APPLIED FOR.
(Continue on separate sheet, if more space is needed).
DATES: MONTH AND YEAR
FROM

EMPLOYER AND LOCATION

TO

SEAT

CHEST

BACK

C. PARACHUTE RIGGER APPLICANTS:
INDICATE BY TYPE HOW MANY
PARACHUTES PACKED

TYPE WORK PERFORMED

LAP

FOR
MASTER
RATING
ONLY

PACKED AS A SENIOR
RIGGER

MILITARY
RIGGER

I CERTIFY THAT THE STATEMENTS BY ME ON THIS APPLICATION ARE TRUE

IV. APPLICANT'S
CERTIFICATION

A. SIGNATURE

I FIND THIS APPLICANT MEETS THE EXPER-

V.IENCE REQUIREMENTS OF FAR 65 AND IS

B. DATE

DATE

INSPECTOR'S SIGNATURE

FAA DISTRICT OFFICE

ELIGIBLE TO TAKE THE REQUIRED TESTS.

Emp.

.reg.

D.O.

.seal .con iss.

Act

.lev .TR .s.h. .Src

#rte

FOR FAA USE ONLY
Rating (1)

LIMITATIONS

FAA Form 8610-2 (2-85) SUPERSEDES PREVIOUS EDITION

Electronic Version (Adobe)

Rating (2)

Rating (3)

Rating (4)

Results of Oral and Practical Tests
MECHANIC

PARACHUTE RIGGER

I. GENERAL - Airframe and powerplant
PASS

PASS

EXPIRATION
DATE:

FAIL

TYPE

ORAL TEST

EXPIRATION
DATE:

QUES.
NO.
PRACTICAL TEST

FAIL

SEAT

PASS

FAIL

BACK

PASS

FAIL

CHEST

PASS

FAIL

LAP

PASS

FAIL

PASS

FAIL

PROJ.
NO.

REMARKS

II. AIRFRAME STRUCTURES
ORAL TEST

PASS

EXPIRATION
DATE:

FAIL

PASS

EXPIRATION
DATE:

FAIL

QUES.
NO.
PRACTICAL TEST
PROJ.
NO.
III. AIRFRAME SYSTEMS AND COMPONENTS
ORAL TEST

PASS

EXPIRATION
DATE:

FAIL

PASS

EXPIRATION
DATE:

FAIL

QUES.
NO.
PRACTICAL TEST
PROJ.
NO.
IV. POWERPLANT THEORY AND MAINTENANCE
ORAL TEST

PASS

EXPIRATION
DATE:

FAIL

PASS

EXPIRATION
DATE:

FAIL

QUES.
NO.
PRACTICAL TEST
PROJ.
NO.
V. POWERPLANT SYSTEMS AND COMPONENTS
ORAL TEST

PASS

EXPIRATION
DATE:

FAIL

PASS

EXPIRATION
DATE:

FAIL

QUES.
NO.
PRACTICAL TEST
PROJ.
NO.

DESIGNATED EXAMINER'S REPORT
I have personally tested this applicant in accordance with pertinent procedures and standards, and
I HAVE INDICATED

APPROVED (Temporary Certificate Issued)

APPROVED (Temporary Certificate NOT Issued)

THE RESULT AS:

DISAPPROVED

FAR 65.80 - ORAL/PRACTICAL PASSED

ATTACHMENTS:
DATE TEST COMPLETED

REPORT OF WRITTEN TEST

SUPERSEDED CERTIFICATE

LETTER

FAA FORM 8610-2

TEMPORARY CERTIFICATE

SEAL SYMBOL CARD

EXAMINER'S SIGNATURE

DESIGNATION NO.

APPLICANT'S CERTIFICATION
THIS BLOCK MUST BE COMPLETED BY THE APPLICANT AT THE TIME OF ISSUANCE OF TEMPORARY CERTIFICATE (FAA FORM 8060-4)

A. HAVE YOU EVER HAD AN AIRMAN CERTIFICATE SUSPENDED OR REVOKED? . . . . . . . . . . . . . . .
B. HAVE YOU EVER BEEN CONVICTED FOR VIOLATION OF ANY FEDERAL OR STATES STATUTES
PERTAINING TO NARCOTIC DRUGS, MARIJUANA, DEPRESSANT OR STIMULANT
DRUGS OR SUBSTANCES? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
I CERTIFY THAT THE STATEMENTS BY ME ARE TRUE.

NO

Yes If "Yes," explain on an attached sheet.
DATE OF FINAL CONVICTION

NO

YES

B. DATE

A. SIGNATURE

FAA INSPECTOR'S REPORT
I HAVE

WITH THE INDICATED RESULT

EXAMINED THIS APPLICANT'S PAPERS.

APPROVED

PERSONALLY TESTED THIS APPLICANT IN
ACCORDANCE WITH PERTINENT PROCEDURES
AND STANDARDS.

DISAPPROVED
DATE

INSPECTOR'S SIGNATURE

Electronic Version (Adobe)

PARACHUTE SEAL
SYMBOL ASSIGNED
ANSWER SHEET GRADED
(Military Competency)
FAA DISTRICT OFFICE