APPLICATION FOR – Check the appropriate box.

CLASS OF AIRMAN MEDICAL CERTIFICATE APPLIED FOR – Check the appropriate box for the class of airman medical certificate for which you are making application.

FULL NAME If your name has changed for any reason, list current name on the application and list any former name(s) in the EXPLANATIONS box of number 18 on the application.

SOCIAL SECURITY NUMBER – The social security number is optional; however, its use as a unique identifier does eliminate mistakes.

ADDRESS – Give permanent mailing address and country. Include your complete nine digit ZIP code if known. Provide your current area code and telephone number.

DATE OF BIRTH – Specify month (MM), day (DD), and year (YYYY) in numerals; e.g., 01/31/1950. Indicate citizenship; e.g., U.S.A.

COLOR OF HAIR – Specify as brown, black, blond, gray or red. If bald, so state. Do not abbreviate.

COLOR OF EYES – Specify actual eye color as brown, black, blue, hazel, gray or green. Do not abbreviate.

SEX – Indicate male or female.

TYPE OF AIRMAN CERTIFICATE(S) YOU HOLD – Check applicable block(s). If “Other” is checked, provide name of certificate.

OCCUPATION – Indicate major employment. “Pilot” will be used only for those gaining their livelihood by flying.

EMPLOYER – Provide your employer’s full name. If self-employed, so state.

HAS YOUR FAA AIRMAN MEDICAL CERTIFICATE EVER BEEN DENIED, SUSPENDED, OR REVOKED – If “yes” is checked, give month and year of action in numerals.

TOTAL PILOT TIME TO DATE – Give total number of civilian flight hours. Indicate whether logged or estimated. Abbreviate as Log. or Est.

TOTAL PILOT TIME PAST 6 MONTHS – Give number of civilian flight hours in the 6-month period immediately preceding date of this application. Indicate whether logged or estimated. Abbreviate as Log. or Est.

MONTH AND YEAR OF LAST FAA MEDICAL EXAMINATION – Give month and year in numerals. If none, so state.

DO YOU CURRENTLY USE ANY MEDICATION (Prescription or Nonprescription) – Check “yes” or “no.” If “yes” is checked, give name of medication(s) and indicate if the medication was listed in a previous FAA medical examination. See NOTE below.

Indicate whether you use near vision contact lens(es) while flying.

MEDICAL HISTORY – Each item under this heading must be checked either “yes” or “no.” 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 block. If information has been reported on a previous application for airman medical certificate and there has been no change in your condition, you may note “PREVIOUSLY REPORTED, NO CHANGE” in the EXPLANATIONS box, but you must still check “yes” to the condition. Do not report occasional common illnesses such as colds or sore throats. “Substance dependence” is defined by any of the following: increased tolerance; withdrawal symptoms; impaired control of use; or continued use despite damage to health or impairment of social, personal, or occupational functioning. “Substance abuse” includes the following: use of an illegal substance; use of a substance or substances in situations in which such use is physically hazardous; or misuse of a substance when such misuse has impaired health or social or occupational functioning. “Substances” include alcohol, PCP, marijuana, cocaine, amphetamines, barbiturates, opiates, and other psychoactive chemicals. Arrest, Conviction and/or Administrative Action History – Letter (v) of this subheading asks if you have ever been: (1) arrested and/or convicted (which may include paying a fine, or forfeiting bond or collateral) of an offense involving driving while intoxicated by, while impaired by, or while under the influence of alcohol or a drug; or (2) arrested, convicted and/or subject to an administrative action by a state or other jurisdiction for an offense for which your license was denied, suspended, cancelled, or revoked or which resulted in attendance at an educational or rehabilitation program. Individual traffic arrests and/or convictions are not required to be reported if they did not involve: alcohol or a drug; suspension, revocation, cancellation, or denial of driving privileges; or attendance at an educational or rehabilitation program. If “yes” is checked, a description of the arrest(s), and/or conviction(s), and/or administrative action(s) must be given in the EXPLANATIONS box. The description must include: (1) the alcohol or drug offense for which you were arrested and/or convicted or the type of administrative action involved (e.g., attendance at an alcohol treatment program in lieu of conviction; license denial, suspension, cancellation, or revocation for refusal to be tested; educational safe driving program for multiple speeding arrests and/or convictions, etc.); (2) the name of the state or other jurisdiction involved; and (3) the date of the arrest(s), and/or convictions and/or administrative action(s). The FAA may check state motor vehicle driving licensing records to verify your responses. Letter (w) of this subheading asks if you have ever had any other (nontraffic) convictions (e.g., assault, battery, public intoxication, robbery, etc.). If so, name the charge for which you were convicted and the date of the conviction in the EXPLANATIONS box. See NOTE below

VISITS TO HEALTH PROFESSIONAL WITHIN LAST 3 YEARS – List all visits in the last 3 years to a physician, physician assistant, nurse practitioner, psychologist, clinical social worker, or substance abuse specialist for treatment, examination, or medical/mental evaluation. List visits for counseling only if related to a personal substance abuse or psychiatric condition. Give date, name, address, and type of health professional consulted and briefly state reason for consultation. Multiple visits to one health professional for the same condition may be aggregated on one line. Routine dental, eye and FAA periodic medical examinations and consultations with your employer-sponsored employee assistance program (EAP) may be excluded unless the consultations were for your substance abuse or unless the consultations resulted in referral for psychiatric evaluation or treatment. See NOTE below.

APPLICANT’S DECLARATION – Two declarations are contained under this heading. The first authorizes the National Driver Register to release adverse driver history information, if any, about the applicant to the FAA. The second certifies the completeness and truthfulness of the applicant’s responses on the medical application. The declaration section must be signed and dated by the applicant after the applicant has read it.