CERTIFICATION FILES CURRENT ( ) USE INSTRUCTIONS COMPUTERIZED FORMS O.K. COPIES O.K. (WITH ORIGINAL SIGNATURES) NO REDUCED COPIES
CERTIFICATION FILES ALWAYS COMPARE EXISTING CERTIFICATE AND MEDICAL WITH INFORMATION PROVIDED ON
APPLICATION INFORMATION SECTION I: TYPE OF CERTIFICATION AIRCRAFT CATAGORY & CLASS REEXAMINATION ? TITLE 49 USC SECTION CONDUCTED BY INSPECTORS ONLY
APPLICATION INFORMATION NAME: LAST, FIRST, MIDDLE FULL NAME REQUIRED NO MIDDLE NAME ( N M N ) INITIAL ONLY ( I O ) NOT ON TEMPORARY CERTIFICATE NOT ON NOTICE OF DISAPPROVAL
APPLICATION INFORMATION SOCIAL SECURITY NUMBER NONE DO NOT USE DO NOT LEAVE BLANK
APPLICATION INFORMATION DATE OF BIRTH PLACE OF BIRTH CITY, STATE COUNTY, STATE CITY, COUNTRY (FOREIGN)
APPLICATION INFORMATION PERMANENT ADDRESS RESIDENCE NUMBER & STREET P.O. BOX OR RURAL ROUTE MAP OR WRITTEN DESCRIPTION TEMPORARY ADDRESS PROVIDE PERMANENT ADDRESS ATTACH NOTE REQUESTING CERT. BE MAILED TO TEMPORARY ADDRESS
APPLICATION INFORMATION NATIONALITY COUNTRY NAME READ, SPEAK, WRITE, AND UNDERSTAND ENGLISH DPE MUST VERIFY
APPLICATION INFORMATION HEIGHT IN INCHES NO FRACTIONS OR TENTHS WEIGHT IN POUNDS NO FRACTIONS OR TENTHS
APPLICATION INFORMATION COLOR OF HAIR BLACK RED BROWN BLOND GRAY BALD
APPLICATION INFORMATION COLOR OF EYES BLUE BROWN BLACK HAZEL GREEN GRAY
APPLICATION INFORMATION SEX TEMP. CERT. MUST MATCH HOLD OR EVER HELD FAA PILOT CERTIFICATE INCLUDES STUDENT CERT. NOT INSTRUCTOR CERT. MOST RECENT ISSUE DATE
APPLICATION INFORMATION MEDICAL CERTIFICATE CLASS: 1ST, 2ND, 3RD DATE ISSUED MUST BE VALID NAME OF EXAMINER FOREIGN EXAMINER NAME ? USE “ENDORSED”
APPLICATION INFORMATION ITEM “U” DRUG CONVICTION MUST BE CHECKED DOES NOT INCLUDE ALCOHOL CONVICTIONS GREATER THAN 1 YEAR FROM CONVICTION DATE CHECK WITH FSDO
APPLICATION INFORMATION MEDICAL STATEMENT FOR GLIDER OR BALLOON NO LONGER ON APPLICATION
BASIS OF APPLICATION COMPLETION OF REQUIRED TEST 2 AIRCRAFT (C-172 / C-172RG) TOTAL TIME THIS AIRCRAFT PIC THIS AIRCRAFT
BASIS OF APPLICATION GRADUATE OF APPROVED SCHOOL VERIFY GRADUATION CERT. DATES MUST MATCH COURSE MUST MATCH
BASIS OF APPLICATION HOLDER OF FOREIGN LICENSE REQUIRED FOR ANY APPLICATION WHEN FOREIGN LICENSE IS THE BASIS OF EXISTING CERTIFICATE OR QUALIFICATION. MUST LIST ALL RATINGS HELD
RECORD OF PILOT TIME MUST MEET ELIGIBILITY REQUIREMENTS INCLUDING SOLO ROUND DOWN NO TENTHS U.S. BASED ON FOREIGN ADD. MUST MEET PART 61 REQ.
PRIOR FAILED TEST ? MUST BE CHECKED REVIEW NOTICE OF DISAPPROVAL WITHIN PAST 30 DAYS ? NOT APPLICABLE NO LONGER ON APPLICATION
APPLICANT’S CERTIFICATION ORIGINAL SIGNATURE WITHIN 60 DAYS OF TEST MUST NOT BE DATED AFTER RECOMMENDING INSTRUCTOR’S SIGNATURE DATE
INSTRUCTOR’S RECOMMENDATION ORIGINAL SIGNATURE WITHIN 60 DAYS OF TEST MUST NOT BE DATED PRIOR TO APPLICANT’S SIGNATURE DATE CERT. NO. WITH “CFI” LEGIBLE (PRINT NAME)
DESIGNATED EXAMINER’S REPORT CHECK APPLICABLE BOXES CFR (141 GRADUATES) LOCATION OF TEST AIRPORT, CITY, STATE ORIGINAL SIGNATURE DATES: MUST MATCH TEMPORARY
ATTACHMENTSATTACHMENTS CHECK ALL APPLICABLE BOXES
IDENTIFICATIONIDENTIFICATION FULLY DESCRIBE I.D. EXPIRATION DATE REQUIRED EXPIRED PHOTO ID ? NO LONGER ACCEPTED
IDENTIFICATIONIDENTIFICATION , BACK PAGE, LOWER RIGHT HAND CORNER NAME, D.O.B., & CERT. NO. REQUIRED IF IS NOT A DUPLEX FORM
TEMPORARY CERTIFICATES MUST BE TYPED ORIGINAL VS. REISSUANCE EXAMINER’S CERT. NUMBER IN LOWER RIGHT CORNER DATES: ORIGINAL SIGNATURE
NOTICE OF DISAPPROVAL MUST BE TYPED PRACTICAL TEST CHECKED DATES: ORIGINAL SIGNATURE AREAS OF OPERATION FAILED OR NOT TESTED FAILURE NUMBER
KNOWLEDGE TEST VERIFY NAME TYPE OF TEST RESULTS EXPIRATION DATE EMBOSSED SEAL
ASSEMBLY OF FILES ASSEMBLED WITH 1 STAPLE IN UPPER LEFT AS FOLLOWS: TEMPORARY OR DISAPPROVAL SUPERSEDED CERTIFICATE OR PREVIOUS DISAPPROVAL KNOWLEDGE TEST OTHER ATTACHMENTS
PTRS REPORTS REQUIRED FOR EACH ACTIVITY DO NOT ATTACH TO CERTIFICATION FILE INSPECTOR NAME CODE SAW (SHARON WITMAN) MSR (MELANIE RAMSEY)
ESTABLISHING ELIGIBILITY MUST REVIEW LOGBOOK PRIOR CERTIFICATION CURRENT APPLICATION MUST KNOW REGULATIONS CURRENT REVISIONS SUBSCRIPTION SERVICE AVIALABLE ON INTERNET
ESTABLISHING ELIGIBILITY CURRENT ENDORSEMENTS 61.65C EXPIRED 61.65D CURRENT 61.65D ERRORS
ESTABLISHING ELIGIBILITY CURRENT INTERPRETATIONS PART 61 & 141 FAQs ????? DESIGNEE UPDATE AVAILABLE ON INTERNET
ESTABLISHING ELIGIBILITY ELIGIBILITY QUESTIONS ? ANY DPE QUESTIONS ? CALL DPE MANAGING INSPECTOR: LARRY ENLOW