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Get Faa Form 04 R0110

FAA Form 8610-1 2-78 SUPERSEDES PREVIOUS EDITION AFS Electronic Forms System - JetForm FormFlow - 12/1998 Detach this part before using form below No certificate may be issued unless a completed application form has been received 14 C. F.R. 65 Form Approved OMB No. 04-R0110 1. NAME Last first middle 2. MECHANIC CERTIFICATE NO. 3. MAILING ADDRESS Number street city State/County ZIP Code Place at which you desire to receive Airworthiness Directives etc. 4a. FIXED BASE OF OPERATIONS PLACE AT WHICH YOU MAY BE LOCATED IN PERSON DURING NORMAL WORKING WEEK 4b. TEAR OFF BEFORE USE U*S* DEPARTMENT OF TRANSPORTATION FEDERAL AVIATION ADMINISTRATION SUPPLEMENTAL INFORMATION MECHANIC S APPLICATION FOR INSPECTION AUTHORIZATION PRIVACY ACT This supplements the form appearing below Mechanic s Application for Inspection Authonzation* The information on the form is solicited under authority of the Federal Aviation Regulations Part 65. Submission of all the data is mandatory. The purpose of this information is to establish eligibility for application for an inspection authorization* The data will be used to identify and evaluate you and maintain a record of your eligibility for the inspection authorization as well as the basis for its renewal* Inspection authorization cannot be completed unless the data is complete. FAA Form 8610-1 2-78 SUPERSEDES PREVIOUS EDITION AFS Electronic Forms System - JetForm FormFlow - 12/1998 Detach this part before using form below No certificate may be issued unless a completed application form has been received 14 C. F*R* 65 Form Approved OMB No* 04-R0110 1. NAME Last first middle 2. MECHANIC CERTIFICATE NO. 3. MAILING ADDRESS Number street city State/County ZIP Code Place at which you desire to receive Airworthiness Directives etc* 4a* FIXED BASE OF OPERATIONS PLACE AT WHICH YOU MAY BE LOCATED IN PERSON DURING NORMAL WORKING WEEK 4b. TELEPHONE NO. MAY BE LOCATED BY TELEPHONE DURING NORMAL WORKING WEEK 5. HAVE YOU HELD A MECHANIC CERTIFICATE WITH BOTH AIRFRAME AND POWERPLANT RATINGS FOR THE 3 YEARS PRECEDING THE DATE OF THIS APPLICATION YES NO 6. HAVE YOU BEEN ACTIVELY ENGAGED FOR AT LEAST THE 2-YEAR PERIOD BEFORE THE DATE OF APPLICATION IN MAINTAINING AIRCRAFT CERTIFICATED AND MAINTAINED IN ACCORDANCE WITH THE FARS 7. HAS YOUR MECHANIC CERTIFICATE AND/OR RATINGS BEEN REVOKED OR SUSPENDED DURING THE 3 YEAR PERIOD PRECEDING THIS APPLICATION 8. HAS AN INSPECTION AUTHORIZATION BEEN DENIED YOU WITHIN 90 DAYS PREVIOUS TO THIS APPLICATION IF ANSWER IS YES EXPLAIN IN REMARKS* 9. HAVE YOU MET THE MINIMUM REQUIREMENTS FOR RENEWAL OF INSPECTION AUTHORIZATION For Renewal Only ALTERATIONS 10. BASIS FOR RENEWAL Number Performed ANNUAL INSPECTIONS PROGRESSIVE INSPEC- RECENT ISSUANCE-IN EFFECT TIONS LESS THAN 90 DAYS BEFORE EXPIRATION DATE REPAIRS 11. AIRCRAFT MAINTENANCE ACTIVITY DURING LAST 2 YEARS NAME AND ADDRESS OF REPAIR STATION FACILITY MANUFACTURER OPERATOR ETC. DATES DESCRIPTION OF ACTIVITY FROM TO PRESENT TO 12. REMARKS 13. CERTIFICATION I certify that the statements made above and in all attachments hereto are correct and true.

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