DD Form 2628 Request for Contractor Flight Crewmember

REQUEST FOR APPROVAL OF CONTRACTOR FLIGHT CREWMEMBER

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-dod-informationcollections@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.

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

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

3. CONTRACTOR'S REQUESTING OFFICIAL (CRO).
I have verified the records of (Crewmember's name)
as a (crew position)
experimental

engineering

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

and request that he/she be approved
for (Check all applicable)

functional check

maintenance test

support

flights in

b. SIGNATURE

type aircraft.
c. DATE SIGNED

4. INSTRUCTOR PILOT/FLIGHT EXAMINER (IP/FE)
I certify that the crewmember above has satisfactorily flown a proficiency flight check on (Date)
a. TYPED NAME (Last, First, Middle Initial)

b. SIGNATURE

.
c. DATE SIGNED

5. GOVERNMENT FLIGHT REPRESENTATIVE (GFR)
APPROVED

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

b. SIGNATURE

DISAPPROVED

DD FORM 2628, SEP 2020

PREVIOUS EDITION IS OBSOLETE.

c. DATE SIGNED