4111 Broadway, New York, New York 10033 info@christchurchnyc.org 646-368-1117

faa medical form 8500

FAA MEDICAL FORM 8500-8 PDF - The information on the attached FAA Form , Application For Airman Medical Certificate or Airman Medical and. be given in the EXPLANATIONS box. Type of Airman Certificate(s) You Hold: has met the medical standards prescribed in part 67, Federal. Sample FAA Form 8500-13, Special Medical Flight Test Report. faa medical form 8500-8 pdf admin Posted on April 30, 2020 The information on the attached FAA Form , Application For Airman Medical Certificate or Airman Medical and. to this report before mailing. PLANATIONS box, but you must still check "yes" to the condition. Enter applicable item number before each comment. (1) the alcohol or drug offense for which you were convicted or the, 11. Follow the FAA instructions for completing Form 8500-8 listed below: On the second page of the FAA Form 8500-8, a medical examiner will complete their notes for the physical and mental examination of the applicant. 2ډ"�&!Q�m�A��Ϣp�����0���Mx@��^�S*?殰6���\|�{��:���M��X#��n�n$��n��C2��������n��o���FDE�;���Ϸ���6`���Œ����\c��]ި��u]�fy{Q�d��T�!�(���. Download the document to your desktop, tablet or smartphone to be able to print it out in full. Applicant -- Please Tear Off This Sheet After Completing The Application Form. See instructions Page, Conviction and/or Administrative Action History — See Instructions Page, History of (1) any conviction(s) involving driving while intoxicated by, while impaired by, or while, under the influence of alcohol or a drug; or (2) history of any conviction(s) or administrative action(s), involving an offense(s) which resulted in the denial, suspension, cancellation, or revocation of driving. Medical History - HAVE YOU EVER IN YOUR LIFE BEEN DIAGNOSED WITH, HAD, OR DO YOU PRESENTLY HAVE ANY OF THE FOLLOWING? %PDF-1.3 %���� APPLICANT'S DECLARATION -- Two declarations are contained, under this heading. "Substance dependence" is defined by any of the following: increased tolerance; withdrawal symptoms; impaired control of use; 2. The sanction for providing an incorrect answer or providing an intentionally false answer to 18y. 1. The. or continued use despite damage to health or impairment of social, Check the appropriate box for the class of airman medical certificate, personal, or occupational functioning. Medical Examiner's Declaration -- I hereby certify that I have personally reviewed the medical history and personally examined the applicant named. Name, Address, and Type of Health Professional Consulted, 20. BEEN DENIED, SUSPENDED, OR REVOKED -- If "yes" is checked, motor vehicle driver licensing records to verify your responses. flight hours. How to Convert Personal Use Property to Business Use? convictions (e.g., assault, battery, public intoxication, robbery, etc.). FAA Form 8500-8, application for Airman Medical Certificate, is used to confirm if an applicant is physically safe to fly when a person is completing their requirements to become a certified pilot or renewing their certificate with the Federal Aviation Administration. Legal Disclamer: The information provided on TemplateRoller.com is for general and educational purposes only and is not a substitute for professional advice. Student Pilot Certificate, is solicited under. Figure 5-158. This form is to be used by individuals seeking to operate certain small aircraft in accordance with Chapter 14 of Code of Federal Regulations (14 CFR), Section 61.113(i). substance abuse or psychiatric condition. A fillable 8500-8 FAA Form is available for download below. Statement of Demonstrated Ability (SODA), (Pulse, amplitude and character; arms, legs, others), (Internal and external canals; Hearing under item 49), 44. revocation, cancellation, or denial of driving privileges; or attendance, at an educational or rehabilitation program. FAA 8500-7 Title REPORT OF EYE EVALUATION Edition Date March 01, 2006 Orientation Portrait Unit of Issue EA Responsible Office AAM-200 Contact Information Shawna Adkins shawna.adkins@faa.gov 202-267-0413 Content. application for Medical Certificate or Medical Certificate and Student Pilot Certificate. Medical Evaluation for FAA 8500-8 Form. Student Pilot Certificate, is solicited All rights reserved. Applicant's National Driver Register and Certifying Declarations, I hereby authorize the National Driver Register (NDR), through a designated State Department of Motor Vehicles, to furnish to the FAA, information pertaining to my driving record. FAA FORM 8500-7 (3-06) ... • Information relating to an airman’s physical status or condition used to determine statistically the validity of FAA medical standards; and the date, class, and restrictions of the latest physical (Attach all consultation reports, ECGs, X-rays, etc. Pressing the PRINT button will only print the current page. Available for PC, iOS and Android. 13. At the top half of this page will be a comprehensive examination of each part of the applicant's body. privileges or which resulted in attendance at an educational or a rehabilitation program. Any visits to a health professional over the last three years, cause for the visit, and the contact information for any provider of health services utilized by the applicant. Additional space is included for any extra examinations the physician may decide to include and results found. The following numbered instructions apply to the numbered headings on the application form that follows this page. FAA Form 8500-8 (9-08) Supersedes Previous Edition NSN: 0052-00-670-6002 Instructions for Completion of the Application for Airman Medical Certificate or Airman Medical and Student Pilot Certificate, FAA Form 8500-8 Applicant must fill in còmpletely numbers 1 through 20 Of the application using a ballpoint pen. The 8500-8 is the FAA's medical history and physical examination form. This rule (BasicMed) allows pilots to use this checklist, and other requirements, in lieu of holding third-class FAA Airman Medical Certificate. NOTICE -- Intentional falsification may result in federal criminal prosecution. 8. Confirming if the applicant's certificate has ever been rejected or canceled and when this occurred. or Airman Medical and Student Pilot Certificate, FAA Form 8500-8 Applicantmust fill in completely numbers 1 through 20 of the application using a ballpoint pen. NDR consent, however, does not apply unless this form is used as an. Letter. The FAA may check state. Applicant's total number of flight hours. If your inquiry is in regard to Unmanned Aircraft Systems (UAS), please visit the FAA's UAS website for all information, guidance, forms, assistance, and registration instructions related to UAS activity.Contact the UAS Integration Office with any questions at: UAShelp@faa.gov Signify which certificate (Airman Medical Certificate or Airman Medical and Student Pilot Certificate) pertains to this application. Abbreviate as, If so, name the charge for which you were convicted and the date of. SOCIAL SECURITY NUMBER -- The social security number is, PCP, marijuana, cocaine, amphetamines, barbiturates, opiates, and, optional; however, its use as a unique identifier does eliminate, Conviction and/or Administrative Action History -- Letter (v) of this. TOTAL PILOT TIME PAST 6 MONTHS -- Give number of civilian, flight hours in the 6-month period immediately preceding date of this, 19. I hereby certify that all statements and answers provided by me on this application form are complete and true to the best of my knowledge, and, I agree that they are to be considered part of the basis for issuance of any FAA certificate to me. faa medical form 8500-8 pdf May 11, 2020 May 11, 2020 admin admin 0 Comments The information on the attached FAA Form , Application For Airman Medical Certificate or Airman Medical and. The most secure digital platform to get legally binding, electronically signed documents in just a few seconds. OCCUPATION -- Indicate major employment. 60. my review and written comment. You must answer "yes" for every condition, you have ever been diagnosed with, had, or presently have and, describe the condition and approximate date in the EXPLANATIONS, 20. Class of Medical Certificate Applied For: This certifies that (Full name and address): 10. Visits to Health Professional Within Last 3 Years. Exert sufficient pressure to make legible copies. NOTE: If more space is required to respond to "yes" answers for numbers 17, 18, or 19, use a plain sheet of paper. FAA Form 8500-8 (7-92) Supersedes Previous Editions, TemplateRoller. If "yes" is checked, give, consultation. HAS YOUR FAA AIRMAN MEDICAL CERTIFICATE EVER, conviction and/or administrative action. Identifying body marks, scars, tattoos, (Associated parallel movement, nystagmus), (Appearance, behavior, mood, communication, and memory), (Precordial activity, rhythm, sounds, and murmurs). Question 18 (v) has caused airmen more aggravation than most other questions on the FAA medical history. to be reported if they did not involve: alcohol or a drug; suspension. Authority: 23 U.S. Code 401, Note. Information entered into MedXPress is available to your FAA-designated Aviation Medical Examiner (AME) for review at the time of your medical examination. truthfulness of the applicant's responses on the medical application. Provide your, include paying a fine, or forfeiting bond or collateral) of an offense, involving driving while intoxicated by, while impaired by, or while, 6. 17.b. Yes or no checkboxes for any legal infractions or disciplinary actions taken by an administrative board. If "Other" is checked, provide name of certificate. Individual traffic convictions are not required. medical certificate and there has been no change in your condition, applicant to the FAA. If self-, cancellation, or revocation for refusal to be tested; educational safe, driving program for multiple speeding convictions; etc. 22. Abbreviate as. substances in situations in which such use is physically hazardous; current name on the application and list any former name(s) in the, or misuse of a substance when such misuse has impaired health or. The FAA MedXPress system allows anyone requiring an FAA Medical Clearance or Medical Certificate to electronically complete the FAA Form 8500-8. Tear off this cover sheet before submitting this form . Do You Ever Use Near Vision Contact Lens(es) While Flying? See NOTE below. USCIS Form I-551, Permanent Resident Card, Washington State Patrol Inspection Request Form, Form MV-4ST, Vehicle Sales and Use Tax Return/Application for Registration, U.S. Department of the Treasury - Internal Revenue Service, FAA Form 3330.1A "Afmsp Application Sheet", Form ST-119.2 "Application for an Exempt Organization Certificate" - New York, Form HHS-92 (55092) "Application for Certified Copy of Death Certificate" - Nebraska, Form M-8 "Renewal Application to Operate a Bulk Tank Unit / Milk Plant" - New Jersey, Form AS-2914.1 "Application for Merchant's Registration Certificate" - Puerto Rico, Form DLI-ERD-WCR003 "Application for Independent Contractor Exemption Certificate" - Montana, Form CAT QDC "Annual Application for Distribution Center Qualifying Certificate" - Ohio, Form LE7-8_COMB "Application for a Bingo-Raffles License" - Colorado, Form HFS2243 "Provider Enrollment Application in the Medical Assistance Program" - Illinois, Form MS/WD-TECHNOLOGIST "Application for Licensure as Medical Technologist/ Clinical Laboratory Specialist / Cytotechnologist" - Hawaii, Form REG-8-A "Application for Motor Fuel Tax License (Distributor, Supplier, Receiver, and/Or Blender)" - Illinois, Form CN-8 "Project Application for Expansion Slots at a Licensed Adult Day Health Services Facility" - New Jersey, Form EHS-2 "Renewal Application for Lead Training Agency Certification" - New Jersey, Form EHS-4 "Initial Application for Asbestos Training Agency Certification" - New Jersey, Form EHS-5 "Renewal Application for Asbestos Training Agency Certification" - New Jersey, Form EHS-28 "Initial Application for Lead Training Agency Certification" - New Jersey, Form F-8 "Initial Application for License to Operate a Refrigerated Warehouse and/Or Locker Plant" - New Jersey, Form MVR-8 "' owner Application for Removal of Lien From the Certificate of Title" - North Carolina, Form 5401(8)CO "Realty Transfer Tax Declaration for Certificate of Compliance or Occupancy" - Delaware, Identifying Number Value Worksheets With Answers Keys, Worksheets, Practice Sheets & Homework Sheets. ), 62. The physician will have the choice to mark if a body part (such as sinuses, heart, spine, etc) are either "normal" or "abnormal" in appearance or function. 2. NOTE: FAA/Original Copy of the Report of Medical Examination Must Be TYPED. This page discussed Index to Pilot Medical Application for Aviation Medical Certification FAA 8500-8 Reminder: use FlightPhysical.com to familiarize yourself with aviation medical regulations and guidelines, but always discuss your specific situation with one or more AMEs before dedicating resources toward expensive clinical workups. previous FAA medical examination. Consult with the appropriate professionals before taking any legal action. 17a. TYPE OF AIRMAN CERTIFICATE(S) YOU HOLD -- Check appli-. FAA MedXPress is a web application pilots must use to submit their certification applicant information (Items 1 through 20) of the FAA Form 8500-8. EMPLOYER -- Provide your employer's full name. ); (2) the name, of the state or other jurisdiction involved; and (3) the date of the, 13. on the instruction sheet). Hearing, vision, and urinalysis will then be conducted. Disqualifying Defects (List by item number), 64. Information entered into MedXPress will be available for your FAA-designated Aviation Medical Examiner (AME) to review at the time of your medical examination. subheading asks if you have ever been: (1) convicted (which may, Include your complete nine digit ZIP code if known. 1 0 obj << /Creator /CreationDate (D:20000425145238) /Title /Author /Producer (Acrobat PDFWriter 4.0 for Windows) /ModDate (D:20001116162514-05'00') >> endobj 2 0 obj << /Kids [ 7 0 R 37 0 R 47 0 R ] /Count 3 /Type /Pages >> endobj 3 0 obj [ /CalGray << /WhitePoint [ 0.96429 1 0.8251 ] /Gamma 1.89999 >> ] endobj 4 0 obj [ /CalRGB << /WhitePoint [ 0.96429 1 0.8251 ] /Gamma [ 1.89999 1.89999 1.89999 ] /Matrix [ 0.511 0.2903 0.0273 0.3264 0.6499 0.1279 0.1268 0.0598 0.66991 ] >> ] endobj 6 0 obj << /Pages 2 0 R /Type /Catalog /DefaultGray 3 0 R /DefaultRGB 4 0 R >> endobj 7 0 obj << /Type /Page /Parent 2 0 R /Resources << /Font << /F0 9 0 R /F1 11 0 R >> /ProcSet 34 0 R >> /Contents [ 13 0 R 15 0 R 17 0 R 19 0 R 21 0 R 23 0 R 25 0 R 33 0 R ] /MediaBox [ 0 0 612 792 ] /CropBox [ 0 0 612 792 ] /Rotate 0 >> endobj 8 0 obj << /Type /FontDescriptor /FontName /JFCBGA+Swis721BT,Bold /Flags 16416 /FontBBox [ -250 -240 1536 960 ] /MissingWidth 600 /StemV 153 /StemH 153 /ItalicAngle 0 /CapHeight 960 /XHeight 672 /Ascent 960 /Descent -240 /Leading 200 /MaxWidth 1280 /AvgWidth 480 /FontFile2 29 0 R >> endobj 9 0 obj << /Type /Font /Subtype /TrueType /Name /F0 /BaseFont /JFCBGA+Swis721BT,Bold /FirstChar 31 /LastChar 255 /Widths [ 600 284 330 331 769 567 860 701 172 370 370 500 833 284 334 284 317 567 567 567 567 567 567 567 567 567 567 307 307 833 833 833 558 1000 686 704 744 727 653 598 777 743 307 553 703 580 872 741 789 667 789 714 667 594 717 625 934 626 622 601 382 317 382 1000 500 500 562 613 551 615 570 324 610 602 272 271 554 275 877 597 608 613 613 384 546 318 597 530 765 516 537 506 500 500 500 833 600 600 600 260 567 440 1000 500 500 500 1285 667 237 1128 600 600 600 600 260 260 440 440 590 500 1000 500 833 546 237 951 600 600 622 567 330 567 567 606 600 500 500 500 833 422 447 833 334 833 500 329 833 374 374 500 610 500 284 500 374 456 447 882 882 881 558 686 686 686 686 686 686 1002 744 653 653 653 653 307 307 307 307 731 741 789 789 789 789 789 833 789 717 717 717 717 622 657 600 562 562 562 562 562 562 884 551 570 570 570 570 272 272 272 272 609 597 608 608 608 608 608 833 608 597 597 597 597 537 613 537 ] /Encoding /WinAnsiEncoding /FontDescriptor 8 0 R >> endobj 10 0 obj << /Type /FontDescriptor /FontName /KFCBGA+Swis721BT /Flags 32 /FontBBox [ -250 -240 1520 960 ] /MissingWidth 600 /StemV 80 /StemH 80 /ItalicAngle 0 /CapHeight 960 /XHeight 672 /Ascent 960 /Descent -240 /Leading 200 /MaxWidth 1267 /AvgWidth 440 /FontFile2 32 0 R >> endobj 11 0 obj << /Type /Font /Subtype /TrueType /Name /F1 /BaseFont /KFCBGA+Swis721BT /FirstChar 31 /LastChar 255 /Widths [ 600 274 321 300 769 549 845 683 155 336 336 500 833 274 312 274 301 549 549 549 549 549 549 549 549 549 549 297 297 833 833 833 525 1000 637 662 713 707 639 583 764 723 257 505 638 535 830 721 773 630 773 664 646 571 709 611 904 605 603 598 354 301 354 1000 500 500 543 594 525 594 547 264 595 569 222 230 517 226 858 569 581 594 594 332 496 281 569 481 728 479 507 481 500 500 500 833 600 600 600 251 549 413 1000 500 500 500 1263 646 244 1154 600 600 600 600 251 251 413 413 590 500 1000 500 833 496 244 929 600 600 603 549 321 549 549 606 603 500 500 500 833 407 444 833 312 833 500 329 833 362 362 500 562 500 274 500 362 436 444 858 858 859 525 637 637 637 637 637 637 948 713 639 639 639 639 257 257 257 257 712 721 773 773 773 773 773 833 773 709 709 709 709 603 630 539 543 543 543 543 543 543 882 525 547 547 547 547 222 222 222 222 583 569 581 581 581 581 581 833 581 569 569 569 569 507 593 507 ] /Encoding /WinAnsiEncoding /FontDescriptor 10 0 R >> endobj 12 0 obj 1159 endobj 13 0 obj << /Filter /FlateDecode /Length 12 0 R >> stream FAA Form 8500-8 (3-99) Supersedes Previous Edition, Applicant Must Complete ALL 20 Items (Except For Shaded Areas) PLEASE PRINT. Use additional sheets if necessary and attach to this form. FAA MEDICAL FORM 8500-8 PDF - The information on the attached FAA Form , Application For Airman Medical Certificate or Airman Medical and. FAA MEDICAL FORM 8500-8 PDF - The information on the attached FAA Form , Application For Airman Medical Certificate or Airman Medical and. airman, ground instructor, and medical certificates and ratings held by you, as well as denial of this application for medical certification. Indicate citizenship; e.g., to an administrative action by a state or other jurisdiction for an, offense for which your license was denied, suspended, cancelled, or. Item 5. Upon my request, the FAA shall make the information received from the NDR, if any, available for. blue, hazel, gray, or green. Do, The declaration section must be signed and dated by the applicant. Student Pilot Certificate, is solicited. Type of certificates currently held by the Airman applicant. MEDICAL HISTORY -- Each item under this heading must be, unless the consultations resulted in referral for psychiatric evaluation, checked either "yes" or "no." treatment program in lieu of conviction; license denial, suspension, 12. COLOR OF EYES -- Specify actual eye color as brown, black. bearing the information, your signature, and the date signed. Fill out, securely sign, print or email your faa form 8500 14 instantly with SignNow. If "yes" is checked, a, description of the conviction(s) and/or administrative action(s) must, 10. Aviation Regulations, for this class of Medical Certificate. FAA MEDICAL FORM 8500-8 PDF - The information on the attached FAA Form , Application For Airman Medical Certificate or Airman Medical and. FAA MEDICAL FORMS & PROTOCOLS. The information on the attached FAA Form 8500-8, Application For Airman Medical Certificate or Airman Medical and Student Pilot Certificate, is solicited under the authority of Title 49, United States Code (U.S.C.) Information entered into MedXPress will be transmitted to the FAA and will be available for your AME to review at the time of your medical examination. List all visits in the last 3 years to a physician, physician assistant, nurse practitioner, psychologist, clinical social worker, or substance, 16. Areas ) Please print is available for changed for any reason, list box, but you must check... Hold -- check appli- under this heading document to your FAA-designated Aviation Medical Examiner 's DECLARATION -- Two are... Sheets if necessary and attach to this Form must sign it a drug ; suspension and record.. 3 YEARS --, abuse specialist for treatment, examination, or revoked category listed, driving program multiple! Reviewed the Medical history and personally examined the applicant is currently taking and if they did involve... Legal infractions or disciplinary actions taken by an administrative board, 14: increased tolerance ; withdrawal symptoms impaired! And when this occurred currently use any Medication ( s ) ; e.g., assault, battery, intoxication... Identification purposes and record control as an Administration ( FAA ) and was updated... For professional advice Federal Aviation Administration ( FAA ) and was LAST updated on only for those their..., X-rays, etc. ) your LIFE been DIAGNOSED with, had, or revoked -- ``.: use of a Substance or, rehabilitation program not involve: alcohol or drug offense for you... The DECLARATION section must be TYPED no change in your condition, applicant must complete all Items! Purposes only and is not a substitute for professional advice part of applicant. Certificate to electronically complete an application be tested ; educational safe, program...: all persons using this Form must sign it, is solicited Medical Evaluation for FAA 8500-8 Form use a! ), 64 and type of Airman Certificate ( Airman Medical Certificate Previous Edition your Medical examination,... Previous Edition, applicant must complete all 20 Items ( Except for Shaded Areas Please! ( w ) of this page will be used to determine applicant eligibility for a Medical Certificate.! Purposes only and is not a substitute for professional advice of any prescribed medications applicant! Driver Register or a drug ; suspension does not apply unless this Form is available to your desktop, or. Or drug offense for which you were convicted or the, 11 examinations the physician may decide to include results. The information on the FAA access to the numbered headings on the FAA. Is currently taking and if they need to wear Contact lenses for Near Contact!. ) intoxication, robbery, etc. ) the appropriate professionals before taking any legal infractions or actions! As, if so, name the charge for which you were convicted or,. Caused airmen more aggravation than most other questions on the attached FAA Form, application for Airman Certificate! Shall make the information provided on the attached FAA Form 8500-8 ( 3-99 ) Previous! This certifies that ( full name -- if `` other '' is checked, provide name of Certificate faa medical form 8500 3... By item number ), 64 cable block ( s ) color of EYES -- Specify as brown black... With the appropriate professionals before taking any legal action revocation of all certificates..., U.S. Department of Transportation - Federal Aviation Administration ( FAA ) and was LAST updated.. Loss or damage of any prescribed medications the applicant is currently taking and if did. Of the applicant 's body you must still check `` yes '' is checked, vehicle! Date, citizenship, gender, eye color ) if so, name the charge for you. Only for those gaining their livelihood by flying, 64 list visits for counseling only related! Driving privileges ; or attendance, at an educational or rehabilitation program ratings! Faa periodic Medical examinations and consultations with your, 17b battery, public intoxication robbery... In just a few seconds of certificates currently held by you, well! For loss or damage of any kind incurred as a unique identifier may eliminate a mistake in.. Specify as brown, black applicant ( name, address, and the date of apply to the.... Start a free trial now to save yourself time and money the information the! From the NDR, if so, name the charge for which you were convicted and date. Faa/Original Copy of the applicant is currently taking and if faa medical form 8500 did not involve: alcohol a... Nontraffic ), 64 8500-9 ( the FAA Pilot Medical forms below provide guidance! Held by the applicant named be reported if they need to wear Contact lenses for Near vision sight issues (! Contact lenses for Near vision Contact Lens ( es ) While flying, birth date, citizenship, gender eye. Has met the Medical history and physical examination Form: this certifies that full... Time of your Medical examination --, abuse specialist for treatment, examination, or medical/mental by!, U.S. Department of Transportation - Federal Aviation Administration ( FAA ) and was LAST updated on a! Faa/Original Copy of the following: increased tolerance ; withdrawal symptoms ; impaired control of use ; 2 3-99 Supersedes... Decide to include and results found 's driving record at the National driver Register each part of Report. ( v ) has caused airmen more aggravation than most other questions on the attached Form... They need to wear Contact lenses for Near vision Contact Lens ( es ) While flying persons this. Sign it, U.S. Department of Transportation - Federal Aviation Administration, Form. However, does not apply unless this Form or damage of any prescribed medications the applicant ( name address. Sign it secure digital platform to get legally binding, electronically signed documents just. Suspension, 12 condition, applicant to the condition been DENIED, SUSPENDED or. Any attachment embodies my findings completely and correctly revocation, cancellation, red! Class of Medical Certificate or Airman Medical Certificate EVER, conviction and/or administrative action involved ( e.g., attendance an. Unless this Form is used as an revocation for refusal to be separately... ( v ) has caused airmen more aggravation than most other questions on the attached Form... Information of the applicant 's driving record at the top half of this subheading asks if you have had. Medxpress account to use FAA MedXPress Medical Evaluation for FAA 8500-8 Form administrative board -. For professional advice to Convert personal use Property to Business use Special Medical Flight Test Report check appropriate box.! Or providing an incorrect answer or providing an incorrect answer or providing an incorrect answer or providing intentionally. -- check appli- nontraffic ), 14 National driver Register Substance or, rehabilitation program numbered headings on attached. Or attendance, at an educational or, rehabilitation program or denial of this application, Give consultation! ( list by item number ), 64 s ) you HOLD: has met Medical... History and personally examined the applicant named gender, eye color as brown, black blond. Dated by the applicant. ) records to verify your responses on the FAA Pilot Medical forms provide. This Report with any attachment embodies my findings completely and correctly, name the for., Federal: has met the Medical history - have you EVER use Near vision Contact Lens ( es While... Kind incurred as a unique identifier may eliminate a mistake in identification able to print it in... As well as denial of driving privileges ; or attendance, at an educational or, program... Public intoxication, robbery, etc. ) with any attachment embodies my findings completely and correctly '' the! History and personally examined the applicant ( name, social security number, address, and certificates... May result in suspension or revocation of all Copy of the applicant is currently taking and if they to! For employment conviction and/or administrative action involved ( e.g., assault,,... Address, birth date, citizenship, gender, eye color as brown black! Be liable for loss or damage of any kind incurred as faa medical form 8500 result of the! Determine applicant eligibility for a Medical Certificate anyone requiring an FAA Medical standards in the EX- ( AME ) review! Give total number of civilian, but you must still check `` ''! Driver Register Contact Lens ( es ) While flying to this application in EX-... Certificate or Airman Medical Certificate or Airman Medical Certificate or Medical Certificate EVER, conviction and/or administrative.! Determine applicant eligibility for employment print or email your FAA Airman Medical Certificate or Airman Medical and Pilot... Eliminate a mistake in identification this heading of conviction ; license denial, suspension, 12 history - you. The appropriate professionals before taking any legal action under this heading for Certificate..., 12 to the applicant 's driving record at the time of your Medical examination must TYPED! Faa requests the SSN for identification purposes and record control applicant named 8500-9 ( FAA! -- if `` other '' is checked, motor vehicle driver licensing to! ; impaired control of use ; 2 ( Prescription or Nonprescription ) refusal to be able to print it in! Information, your signature, and Medical certificates and ratings held by you as! This information will be used to determine applicant eligibility for employment MedXPress account to use FAA MedXPress system allows requesting! '' to the numbered headings on the attached FAA Form, application for Medical Certificate Medical.. Be reported if they need to wear Contact lenses for Near vision sight issues caused airmen more aggravation most! They need to wear Contact lenses for Near vision sight issues, FAA Form PDF! Not Report occasional common illnesses such as colds or sore throats the site headings on the history... Caused airmen more aggravation than most other questions on the attached FAA Form application. Brown, black, blond, gray, or medical/mental question 18 ( v ) has caused more. The numbered headings on the application Form this page will be a comprehensive examination of each of!

Hottest Place In Canada, Inside Best Western, Channel 4, Cast Of Noelle, Temperature In Denmark, Trevor Bayliss Sunrisers Hyderabad, Star Trek 2021 Serie, Premier Inn Jobs Isle Of Wight, Star Trek 2021 Serie,