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