SHANE LIPSON
Designated Pilot Examiner — Evaluation Request
Complete this form after you have booked a reservation date. Please complete it as accurately as possible and submit it before your scheduled checkride date.
*
Required field
Exam Type
Exam Type
*
Standard Flight Exam
Administrative Activity
Activity Type
*
— Select —
SOE Removal
SIC
ATP Limitation Removal
Foreign Pilot Conversion (FPE)
Military Conversion (MCE)
Ground Instructor (GIE)
CFI Renewal (FIRE)
Other
Exam Information
Exam Attempt
*
— Select —
Initial attempt
Retake After Discontinuance
Retake After Disapproval
What Level
*
— Select —
Private
Instrument
Commercial
CFI
CFI - Instrument / Reinstatement
Other
Initial Certificate or Add-On
*
Initial Certificate
Add-On
Category
*
— Select —
ASEL
AMEL
Please specify
— none —
Private ASEL
Private AMEL
Multiengine Private Add-on
Single-Engine Private Add-on
Instrument
Commercial ASEL
Commercial AMEL
Multiengine Commercial Add-on
Single-Engine Commercial Add-on
Flight Instructor ASEL (Initial)
Flight Instructor AMEL (Initial)
Multiengine Flight Instructor Add-on
Single-Engine Flight Instructor Add-on
CFI - Instrument / Reinstatement
Other
FTN Number
IACRA Application Number
Test Date
Test Time (scheduled)
--
AM
PM
Address of Testing Location
Applicant Information
Full Name
Certificate Number
Training Conducted Under
Part 61
Part 141
141 School Number
Home Address
Grade Certificate Held
— Select —
Student
Private
Commercial
ATP
Other
Phone Number
ID Type
— Select —
Drivers License / State ID
Military ID
Passport
Other
Enter State, ID Number, and Expiration Date, if applicable
Email Address
Airport of Primary Training
Medical Class
— Select —
1st Class
2nd Class
3rd Class
Basic Med
Other
Medical Date
Written Test Results
Was a Written Test Required?
Yes
No
Was the Fundamentals of Instructing (FOI) Knowledge Test Required?
Yes
No
Answer No only if you already hold a flight or ground instructor certificate (such as an AGI), hold a current teaching certificate, or teach at an accredited college or university.
Date of FOI Written Test
Date of Written Test
Did You Miss Any Questions?
Yes
No missed codes
List of Codes for Missed Questions
Separate each code with a comma
Aircraft Information
Make / Model Aircraft
N Number
Date of Last Annual
Hours to Next 100 Hour (if required)
Recommending Instructor
Instructor's Name
CFI Certificate #
Telephone #
Instructor's Email
Endorsement Dates (list date of endorsement)
Received flight training in areas XXXXX (private, instrument, or commercial) and certifying applicant is prepared for practical test
§61.39(a)(6)
Training time in last 2 months
§61.39(a)(6)
(date of endorsement)
Reviewed incorrect test answer review
§61.39(a)(6)
If retest: additional training was given
§61.49
Administrative Activity
First Name
*
Last Name
*
FTN (or "paper" for a paper 8710)
*
IACRA Application Number
Certification # Held
*
Phone Number
*
Email
*
Date Scheduled
*
Submit Evaluation Request