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<tbody>
<tr class="odd">
<td colspan="20"><strong>Date:</strong>
<strong><u>     </u></strong></td>
</tr>
<tr class="even">
<td colspan="20"><h1
id="section-1.-fstd-information-and-characteristics"><strong>Section 1.
FSTD Information and Characteristics</strong></h1></td>
</tr>
<tr class="odd">
<td colspan="3"><strong>Sponsor Name:</strong></td>
<td colspan="8"><strong><u>     </u></strong></td>
<td colspan="9"><strong>FSTD Location</strong>:</td>
</tr>
<tr class="even">
<td colspan="3"><strong>Address:</strong></td>
<td colspan="8"><p><strong><u>     </u></strong></p>
<p><strong><u>     </u></strong></p></td>
<td colspan="3"><strong>Physical Address:</strong></td>
<td colspan="6"><p><strong><u>     </u></strong></p>
<p><strong><u>     </u></strong></p></td>
</tr>
<tr class="odd">
<td colspan="3"><strong>City:</strong></td>
<td colspan="8"><strong><u>     </u></strong></td>
<td colspan="3"><strong>City:</strong></td>
<td colspan="6"><strong><u>     </u></strong></td>
</tr>
<tr class="even">
<td colspan="3"><strong>State:</strong></td>
<td colspan="8"><strong><u>     </u></strong></td>
<td colspan="3"><strong>State:</strong></td>
<td colspan="6"><strong><u>     </u></strong></td>
</tr>
<tr class="odd">
<td colspan="3"><strong>Country:</strong></td>
<td colspan="8"><strong><u>     </u></strong></td>
<td colspan="3"><strong>Country:</strong></td>
<td colspan="6"><strong><u>     </u></strong></td>
</tr>
<tr class="even">
<td colspan="3"><strong>ZIP:</strong></td>
<td colspan="8"><strong><u>     </u></strong></td>
<td colspan="3"><strong>ZIP:</strong></td>
<td colspan="6"><strong><u>     </u></strong></td>
</tr>
<tr class="odd">
<td colspan="3"><strong>Manager</strong></td>
<td colspan="8"><strong><u>     </u></strong></td>
<td colspan="3"></td>
<td colspan="6"></td>
</tr>
<tr class="even">
<td colspan="3"><strong>Sponsor ID No:<br />
</strong>(Four Letter FAA Designator)</td>
<td colspan="8"><strong><u>     </u></strong></td>
<td colspan="3"><p><strong>Nearest Airport:</strong></p>
<p>(Airport Designator)</p></td>
<td colspan="6"><strong><u>     </u></strong></td>
</tr>
<tr class="odd">
<td colspan="20"></td>
</tr>
<tr class="even">
<td colspan="8"><strong>Type of Evaluation Requested:</strong></td>
<td colspan="12"><p> <strong>Initial</strong> <strong>Upgrade</strong>
<strong>Continuing Qualification</strong> <strong>Special</strong></p>
<p> <strong>Reinstatement</strong></p></td>
</tr>
<tr class="odd">
<td colspan="2"><strong>Aircraft Make/model/series:</strong></td>
<td colspan="18"><strong><u>     </u></strong></td>
</tr>
<tr class="even">
<td colspan="2"><p><strong>Initial Qualification:</strong></p>
<p>(If Applicable)</p></td>
<td colspan="8"><p><strong>Date: <u>     </u></strong>
<strong>Level</strong> <strong><u>     </u></strong></p>
<p>MM/DD/YYYY</p></td>
<td colspan="4"><strong>Manufacturer’s Identification or Serial
Number</strong></td>
<td colspan="6"><strong><u>               </u></strong></td>
</tr>
<tr class="odd">
<td colspan="2"><p><strong>Upgrade Qualification:</strong></p>
<p>(If Applicable)</p></td>
<td colspan="8"><p><strong>Date:</strong> <strong><u>     </u></strong>
<strong>Level</strong> <strong><u>     </u></strong></p>
<p>MM/DD/YYYY</p></td>
<td colspan="4"> <strong>eMQTG</strong></td>
<td colspan="6"></td>
</tr>
<tr class="even">
<td colspan="6" rowspan="2"><strong>Qualification Basis:
<u>               </u></strong></td>
<td colspan="3"> <strong>A</strong></td>
<td colspan="4"> <strong>B</strong></td>
<td colspan="4"> <strong>Interim C</strong></td>
<td colspan="2"> <strong>C</strong></td>
<td> <strong>D</strong></td>
</tr>
<tr class="odd">
<td colspan="3"> <strong>6</strong></td>
<td colspan="4"> <strong>7</strong></td>
<td colspan="4"> <strong>Provisional Status</strong></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="20"></td>
</tr>
<tr class="odd">
<td colspan="20"><strong>Other Technical Information:</strong></td>
</tr>
<tr class="even">
<td colspan="3"><p><strong>FAA FSTD ID No:</strong></p>
<p>(If Applicable)</p></td>
<td colspan="7"><strong><u>     </u></strong></td>
<td colspan="4"><strong>FSTD Manufacturer:</strong></td>
<td colspan="6"><strong><u>     </u></strong></td>
</tr>
<tr class="odd">
<td colspan="3"><strong>Convertible FSTD:</strong></td>
<td colspan="7"><strong>Yes</strong>:</td>
<td colspan="4"><strong>Date of Manufacture</strong>:</td>
<td colspan="6"><p><strong><u>     </u></strong></p>
<p>MM/DD/YYYY</p></td>
</tr>
<tr class="even">
<td colspan="3"><p><strong>Related FAA ID No</strong>.</p>
<p>(If Applicable)</p></td>
<td colspan="7"><strong><u>     </u></strong>
<strong><u>     </u></strong> <strong><u>     </u></strong></td>
<td colspan="10"><strong>Sponsor FSTD ID No:</strong> <u>     </u></td>
</tr>
<tr class="odd">
<td colspan="10"><strong>Engine model(s) and data revision:</strong>
<u>     </u></td>
<td colspan="10"><strong>Source of aerodynamic model:</strong>
<u>     </u></td>
</tr>
<tr class="even">
<td colspan="10"><strong>FMS identification and revision level:</strong>
<u>     </u></td>
<td colspan="10"><strong>Source of aerodynamic coefficient
data:</strong> <u>     </u></td>
</tr>
<tr class="odd">
<td colspan="10"><strong>Visual system manufacturer/model:</strong>
<u>     </u></td>
<td colspan="10"><strong>Aerodynamic data revision number:</strong>
<u>     </u></td>
</tr>
<tr class="even">
<td colspan="10"><strong>Flight control data revision:</strong>
<u>     </u></td>
<td colspan="10"><strong>Visual system display:</strong>
<u>     </u></td>
</tr>
<tr class="odd">
<td colspan="10"><strong>Mot ion system manufacturer/type:</strong>
<u>     </u></td>
<td colspan="10"><strong>FSTD computer(s) identification:</strong>
<u>     </u></td>
</tr>
<tr class="even">
<td colspan="20"></td>
</tr>
<tr class="odd">
<td colspan="3"><p>National Aviation Authority (NAA):</p>
<p>(If Applicable)</p></td>
<td colspan="17"><u>     </u></td>
</tr>
<tr class="even">
<td colspan="3"><strong>NAA FSTD ID No:</strong></td>
<td colspan="7"><u>     </u></td>
<td colspan="4"><strong>Last NAA Evaluation Date:</strong></td>
<td colspan="6"><u>     </u></td>
</tr>
<tr class="odd">
<td colspan="3"><strong>NAA Qualification Level:</strong></td>
<td colspan="7"><u>     </u></td>
<td colspan="4"></td>
<td colspan="6"></td>
</tr>
<tr class="even">
<td colspan="3"><strong>NAA Qualification Basis:</strong></td>
<td colspan="7"><strong><u>     </u></strong></td>
<td colspan="4"></td>
<td colspan="6"></td>
</tr>
<tr class="odd">
<td colspan="20"></td>
</tr>
<tr class="even">
<td colspan="4"><strong>Visual System</strong> M<strong>anufacturer and
Type:</strong></td>
<td colspan="3"><u>     </u></td>
<td colspan="5"><strong>FSTD Seats Available:</strong> <u>     </u></td>
<td colspan="6"><strong>Motion System Manufacturer and
Type:</strong></td>
<td colspan="2"><u>     </u>:</td>
</tr>
<tr class="odd">
<td><strong>Aircraft Equipment:</strong></td>
<td colspan="6"><p><strong>Engine Type(s):</strong></p>
<p><strong><u>     </u></strong></p>
<p><strong><u>     </u></strong></p></td>
<td colspan="9"><p><strong>Flight Instrumentation:</strong></p>
<p> <strong>EFIS</strong> <strong>HUD</strong> <strong>HGS</strong>
<strong>EFVS</strong></p>
<p> <strong>TCAS</strong> <strong>GPWS</strong> <strong>Plain
View</strong></p>
<p> <strong>GPS</strong> <strong>FMS Type:</strong> <u>     </u></p>
<p> <strong>WX Radar</strong> <strong>Other:</strong>
<u>     </u></p></td>
<td colspan="4"><p>Engine Instrumentation:</p>
<p> <strong>EICAS</strong> <strong>FADEC</strong></p>
<p> <strong>Other:</strong> <u>     </u></p></td>
</tr>
<tr class="even">
<td colspan="20"></td>
</tr>
<tr class="odd">
<td colspan="5"><strong>Airport Models</strong>:</td>
<td colspan="5"><p>3.6.1 <strong><u>     </u></strong></p>
<p>Airport Designator</p></td>
<td colspan="5"><p>3.6.2 <strong><u>     </u></strong></p>
<p>Airport Designator</p></td>
<td colspan="5"><p>3.6.3 <strong><u>     </u></strong></p>
<p>Airport Designator</p></td>
</tr>
<tr class="even">
<td colspan="5"><strong>Circle to Land</strong>:</td>
<td colspan="5"><p>3. 7.1 <strong><u>     </u></strong></p>
<p>Airport Designator</p></td>
<td colspan="5"><p>3. 7.2 <strong><u>     </u></strong></p>
<p>Approach</p></td>
<td colspan="5"><p>3. 7.3 <strong><u>     </u></strong></p>
<p>Landing Runway</p></td>
</tr>
<tr class="odd">
<td colspan="5"><strong>Visual Ground Segment</strong></td>
<td colspan="5"><p>3.8.1 <strong><u>     </u></strong></p>
<p>Airport Designator</p></td>
<td colspan="5"><p>3.8 .2 <strong><u>     </u></strong></p>
<p>Approach</p></td>
<td colspan="5"><p>3. 8.3 <strong><u>     </u></strong></p>
<p>Landing Runway</p></td>
</tr>
</tbody>
</table>

+------------+---+---------------------+---+------+-------+---+-----------------+
| #          |   |                     |   |      |       |   |                 |
| **Section  |   |                     |   |      |       |   |                 |
| 2. Supplem |   |                     |   |      |       |   |                 |
| entary Inf |   |                     |   |      |       |   |                 |
| ormation** |   |                     |   |      |       |   |                 |
+------------+---+---------------------+---+------+-------+---+-----------------+
| **FAA      |   |                     |   |      |       |   |                 |
| Training   |   |                     |   | **P  |       |   |                 |
| Program    |   |                     |   | OI** |       |   |                 |
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|            |   |                     |   | \_\_ |       |   |                 |
|            |   |                     |   | \_\_ |       |   |                 |
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+------------+---+---------------------+---+------+-------+---+-----------------+
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+------------+---+---------------------+---+------+-------+---+-----------------+
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|            | } |                     |   |      |       |   |                 |
+------------+---+---------------------+---+------+-------+---+-----------------+
| **Email:** | [ |                     |   |      |       |   |                 |
|            |   |                     |   |      |       |   |                 |
|            |   |                     |   |      |       |   |                 |
|            |   |                     |   |      |       |   |                 |
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|            | e |                     |   |      |       |   |                 |
|            | } |                     |   |      |       |   |                 |
+------------+---+---------------------+---+------+-------+---+-----------------+
|            |   |                     |   |      |       |   |                 |
+------------+---+---------------------+---+------+-------+---+-----------------+
| **FSTD     |   |                     |   |      |       |   |                 |
| Scheduling |   |                     |   |      |       |   |                 |
| Person**:  |   |                     |   |      |       |   |                 |
+------------+---+---------------------+---+------+-------+---+-----------------+
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+------------+---+---------------------+---+------+-------+---+-----------------+
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|            |   |                     |   | ress |       |   |                 |
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+------------+---+---------------------+---+------+-------+---+-----------------+
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+------------+---+---------------------+---+------+-------+---+-----------------+
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+------------+---+---------------------+---+------+-------+---+-----------------+
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| Contact:** |   |                     |   |      |       |   |                 |
+------------+---+---------------------+---+------+-------+---+-----------------+
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+------------+---+---------------------+---+------+-------+---+-----------------+
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+------------+---+---------------------+---+------+-------+---+-----------------+
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|            |   |                     | * |      |       | . |                 |
|            |   |                     | * |      |       | u |                 |
|            |   |                     |   |      |       | n |                 |
|            |   |                     |   |      |       | d |                 |
|            |   |                     |   |      |       | e |                 |
|            |   |                     |   |      |       | r |                 |
|            |   |                     |   |      |       | l |                 |
|            |   |                     |   |      |       | i |                 |
|            |   |                     |   |      |       | n |                 |
|            |   |                     |   |      |       | e |                 |
|            |   |                     |   |      |       | } |                 |
+------------+---+---------------------+---+------+-------+---+-----------------+
| **ZIP:**   |   | [     ]{.underline} | * |      |       | [ |                 |
|            |   |                     | * |      |       |   |                 |
|            |   |                     | E |      |       |   |                 |
|            |   |                     | m |      |       |   |                 |
|            |   |                     | a |      |       |   |                 |
|            |   |                     | i |      |       |   |                 |
|            |   |                     | l |      |       | ] |                 |
|            |   |                     | : |      |       | { |                 |
|            |   |                     | * |      |       | . |                 |
|            |   |                     | * |      |       | u |                 |
|            |   |                     |   |      |       | n |                 |
|            |   |                     |   |      |       | d |                 |
|            |   |                     |   |      |       | e |                 |
|            |   |                     |   |      |       | r |                 |
|            |   |                     |   |      |       | l |                 |
|            |   |                     |   |      |       | i |                 |
|            |   |                     |   |      |       | n |                 |
|            |   |                     |   |      |       | e |                 |
|            |   |                     |   |      |       | } |                 |
+------------+---+---------------------+---+------+-------+---+-----------------+
| **Tel:**   |   | [     ]{.underline} | * |      |       | [ |                 |
|            |   |                     | * |      |       |   |                 |
|            |   |                     | F |      |       |   |                 |
|            |   |                     | a |      |       |   |                 |
|            |   |                     | x |      |       |   |                 |
|            |   |                     | : |      |       |   |                 |
|            |   |                     | * |      |       | ] |                 |
|            |   |                     | * |      |       | { |                 |
|            |   |                     |   |      |       | . |                 |
|            |   |                     |   |      |       | u |                 |
|            |   |                     |   |      |       | n |                 |
|            |   |                     |   |      |       | d |                 |
|            |   |                     |   |      |       | e |                 |
|            |   |                     |   |      |       | r |                 |
|            |   |                     |   |      |       | l |                 |
|            |   |                     |   |      |       | i |                 |
|            |   |                     |   |      |       | n |                 |
|            |   |                     |   |      |       | e |                 |
|            |   |                     |   |      |       | } |                 |
+------------+---+---------------------+---+------+-------+---+-----------------+

+--------------------------------------+------+------------------------+
| # **Section 3. Training, T           |      |                        |
| esting and Checking Considerations** |      |                        |
+--------------------------------------+------+------------------------+
| **Area/Function/Maneuver**           | *    | **Remarks**            |
|                                      | *Req |                        |
|                                      | uest |                        |
|                                      | ed** |                        |
+--------------------------------------+------+------------------------+
| **Private Pilot - Training /         |      | [     ]{.underline}    |
| Checks:** (142)                      |      |                        |
+--------------------------------------+------+------------------------+
| **Commercial Pilot - Training        |      | [     ]{.underline}    |
| /Checks:**(142)                      |      |                        |
+--------------------------------------+------+------------------------+
| **Multi-Engine Rating - Training /   |      | [     ]{.underline}    |
| Checks** (142)                       |      |                        |
+--------------------------------------+------+------------------------+
| **Instrument Rating -Training /      |      | [     ]{.underline}    |
| Checks** (142)                       |      |                        |
+--------------------------------------+------+------------------------+
| **Type Rating - Training / Checks**  |      | [     ]{.underline}    |
| (135/121/142)                        |      |                        |
+--------------------------------------+------+------------------------+
| **Proficiency Checks** (135/121/142) |      | [     ]{.underline}    |
+--------------------------------------+------+------------------------+
| **CAT I:** (RVR 2400/1800 ft. DH200  |      | [     ]{.underline}    |
| ft)                                  |      |                        |
+--------------------------------------+------+------------------------+
| **CAT II**: (RVR 1200 ft. DH 100 ft) |      | [     ]{.underline}    |
+--------------------------------------+------+------------------------+
| **CAT III** \* (lowest minimum)      |      | [     ]{.underline}    |
| [     ]{.underline} RVR              |      |                        |
| [     ]{.underline} ft.              |      |                        |
|                                      |      |                        |
| **\*** State CAT III                 |      |                        |
| ([\<]{.underline} 700 ft.), CAT IIIb |      |                        |
| ([\<]{.underline} 150 ft.), or CAT   |      |                        |
| IIIc (0 ft.)                         |      |                        |
+--------------------------------------+------+------------------------+
| **Circling Approach**                |      | [     ]{.underline}    |
+--------------------------------------+------+------------------------+
| **Windshear Training**:              |      | [     ]{.underline}    |
+--------------------------------------+------+------------------------+
| **Windshear Training** IAW           |      | [     ]{.underline}    |
| 121.409(d) (121 Turbojets Only)      |      |                        |
+--------------------------------------+------+------------------------+
| **Generic Unusual Attitudes and      |      | [     ]{.underline}    |
| Recoveries** **within the Normal     |      |                        |
| Flight Envelope**                    |      |                        |
+--------------------------------------+------+------------------------+
| **Specific Unusual Attitudes         |      | [     ]{.underline}    |
| Recoveries**                         |      |                        |
+--------------------------------------+------+------------------------+
| **Auto-coupled Approach/Auto Go      |      | [     ]{.underline}    |
| Around**                             |      |                        |
+--------------------------------------+------+------------------------+
| **Auto-land / Roll Out Guidance**    |      | [     ]{.underline}    |
+--------------------------------------+------+------------------------+
| **TCAS/ACAS I / II**                 |      | [     ]{.underline}    |
+--------------------------------------+------+------------------------+
| **WX-Radar**                         |      | [     ]{.underline}    |
+--------------------------------------+------+------------------------+
| **HUD**                              |      | [     ]{.underline}    |
+--------------------------------------+------+------------------------+
| **HGS**                              |      | [     ]{.underline}    |
+--------------------------------------+------+------------------------+
| **EFVS**                             |      | [     ]{.underline}    |
+--------------------------------------+------+------------------------+
| **Future Air Navigation Systems**    |      | [     ]{.underline}    |
+--------------------------------------+------+------------------------+
| **GPWS / EGPWS**                     |      | [     ]{.underline}    |
+--------------------------------------+------+------------------------+
| **ETOPS Capability**                 |      | [     ]{.underline}    |
+--------------------------------------+------+------------------------+
| **GPS**                              |      | [     ]{.underline}    |
+--------------------------------------+------+------------------------+
| **SMGCS**                            |      | [     ]{.underline}    |
+--------------------------------------+------+------------------------+
| **Helicopter Slope Landings**        |      | [     ]{.underline}    |
+--------------------------------------+------+------------------------+
| **Helicopter External Load           |      | [     ]{.underline}    |
| Operations**                         |      |                        |
+--------------------------------------+------+------------------------+
| **Helicopter Pinnacle Approach to    |      | [     ]{.underline}    |
| Landing**s                           |      |                        |
+--------------------------------------+------+------------------------+
| **Helicopter Night Vision            |      | [     ]{.underline}    |
| Maneuvers**                          |      |                        |
+--------------------------------------+------+------------------------+
| **Helicopter Category A Takeoffs**   |      | [     ]{.underline}    |
+--------------------------------------+------+------------------------+