DD Form 2627 Request for Government Approval for Aircrew Qualificatio

CUI (when filled in)
REQUEST FOR GOVERNMENT APPROVAL FOR AIRCREW QUALIFICATIONS AND TRAINING

OMB No. 0704-0347
OMB Approval Expires
20230930

The public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of
this collection of information, including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, at whs.mc-alex.esd.mbx.dd-dodinformationcollections@mail.mil. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a
collection of information if it does not display a currently valid OMB control number.

PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 136, Under Secretary of Defense for Personnel and Readiness; 37 U.S.C. 301a - Incentive pay: aviation career; and DCMA INST 8210.1C, Contractor’s Flight
and Ground Operations.
PURPOSE: Used to monitor and manage individual contract flight/ground crew records.
ROUTINE USES(S): To the Federal Aviation Agency or the appropriate civil aviation authority or foreign military department in the course of certifying individuals, investigative flight
mishaps, and conducting rescue operations. Additional routine uses are listed in the applicable system of records notice, PDCMA 1 DoD, Contractor's Flight and Ground Operations
(https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570147/pdcma-1-dod/)
DISCLOSURE: Voluntary; however, failure to provide the information could result in disapproval of your request to participate in the program.

1. FROM (Name and Address of Contractor's Requesting Official)

2. TO (Name and Address of Government Flight Representative)

3. CREW MEMBER NAME (Last, First, Middle Initial)

4. HAVE YOU EVER BEEN REMOVED FROM
FLIGHT STATUS FOR CAUSE?

6. AIRCRAFT

8. SECURITY CLEARANCE

YES
7. CREW POSITION

5. DATE OF BIRTH
(YYYYMMDD)

NO
9. FAA RATING

10. EDUCATIONAL BACKGROUND
a. HIGH SCHOOL (1) NAME

(2) LOCATION (Include Zip Code)

(3) DATE COMPLETED (YYYYMMDD)

b. COLLEGE(S) OR UNIVERSITY(IES) (1) NAME

(2) LOCATION (Include Zip Code)

(3) DEGREE(S) OBTAINED

c. FLIGHT SCHOOL (1) NAME

(2) DATE COMPLETED
(YYYYMMDD)

(2) DATE COMPLETED
(YYYYMMDD)

d. TEST PILOT SCHOOL (1) NAME

e. SPECIAL PROFESSIONAL SCHOOL(S) (List name of school, location, primary subject of study, and date completed) (Use additional sheets if necessary)

11. HAVE YOU EVER SERVED IN ANY BRANCH OF THE U.S. MILITARY SERVICE? (X one)
b.SERVICE DATES (YYYYMMDD)
a. BRANCH OF SERVICE
(1) FROM

YES (Complete a. - f.)
c. LAST LOCATION

NO

(2) TO

f. ARE YOU NOW A MEMBER OF THE RESERVES OR NATIONAL GUARD? (X one)
d. HIGHEST RANK
e. AERONAUTICAL RATING
(1) BRANCH OF SERVICE
(2) PRESENT RANK
YES (If Yes, specify:)
NO
12. PROVIDE A RESUME OF EXPERIENCE IN THE FLIGHT TEST FIELD.
(Include both engineering and aircrew experience by project, type of aircraft,
and hours flown.)

RESUME ATTACHED. (X if applicable)

13. FLIGHT CREW MEMBER CERTIFICATION. I certify that I have read and understand all of the contractor's procedures and directives pertinent to the
accomplishment of my assigned duty.
b. SIGNATURE
c. DATE SIGNED (YYYYMMDD)
a. TYPED NAME (Last, First, Middle Initial)
14. CONTRACTOR'S REQUESTING OFFICIAL (CRO)
I have verified the records of the crewmember above and request that he/she be approved for qualification training as a (crew position)
for (Check all applicable):
Experimental

Engineering

a. TYPED NAME (Last, First, Middle Initial)

Functional Check

15. GOVERNMENT FLIGHT REPRESENTATIVE (GFR)
a. TYPED NAME (Last, First, Middle Initial)
APPROVED
DISAPPROVED

DD FORM 2627, SEP 2020
PREVIOUS EDITION IS OBSOLETE.

Maintenance Test

b. SIGNATURE

Support flights in

type aircraft.
c. DATE SIGNED (YYYYMMDD)

b. SIGNATURE

CUI (when filled in)

c. DATE SIGNED (YYYYMMDD)
Controlled by:
CUI Category: PROPIN/PRVCY
Distribution/Dissemination Control: FEDCON
POC: