Evaluation Request — Shane Lipson, DPE

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

Certificate / Rating Sought *

Test Date

Test Time (scheduled)

Applicant Information

Full Name

Certificate Number

Home Address

Grade Certificate Held

Phone Number

Training Conducted Under

Part 61 Part 141

ID Type

Enter State, ID Number, and Expiration Date, if applicable

Email Address

FTN Number

IACRA Application Number

Airport of Primary Training

Medical Class

Medical Date

Aircraft Information

Make / Model Aircraft

N Number

Date of Last Annual

Hours to Next 100 Hour (if required)

Testing Location

Address of Testing Location

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

Written Test Results

Was a Written Test Required?

Yes No