**14 CFR PART 135**

**AIRMAN COMPETENCY/INSTRUMENT PROFICENCY CHECK**

+------------+----+---------------+----------+-----------------------+
| **AIRMAN   |    |               | **AIR    |                       |
| DATA**     |    |               | CARRIER  |                       |
|            |    |               | /        |                       |
|            |    |               | OP       |                       |
|            |    |               | ERATOR** |                       |
+------------+----+---------------+----------+-----------------------+
| NAME       |    |               | NAME:    |                       |
| (*last,    |    |               |          |                       |
| first,     |    |               | CER      |                       |
| middle     |    |               | TIFICATE |                       |
| initial)*  |    |               | No.      |                       |
+------------+----+---------------+----------+-----------------------+
| Address:   |    |               | Address: |                       |
|            |    |               |          |                       |
| State:     |    |               | State:   |                       |
| Postal     |    |               | Postal   |                       |
| Code:      |    |               | Code:    |                       |
+------------+----+---------------+----------+-----------------------+
| AIRMAN     | Gr |               | Copies   |                       |
| CE         | ad |               | of the   |                       |
| RTIFICATE: | e: |               | ev       |                       |
|            |    |               | aluation |                       |
|            |    |               | form     |                       |
|            |    |               | provided |                       |
|            |    |               | to:      |                       |
+------------+----+---------------+----------+-----------------------+
|            | N  |               | Airman:  | □ Yes □ No            |
|            | um |               |          |                       |
|            | be |               |          |                       |
|            | r: |               |          |                       |
+------------+----+---------------+----------+-----------------------+
| MEDICAL    | Da | / /           | Training | □ Yes □ No            |
| CE         | te |               | Center:  |                       |
| RTIFICATE: | of |               |          |                       |
|            | E  |               |          |                       |
|            | xa |               |          |                       |
|            | m: |               |          |                       |
+------------+----+---------------+----------+-----------------------+
|            | Cl | □ First □     | Others:  |                       |
|            | as | Second □      | \_\_     |                       |
|            | s: | Third         | \_\_\_\_ |                       |
|            |    |               | \_\_\_\_ |                       |
|            |    |               | \_\_\_\_ |                       |
|            |    |               | \_\_\_\_ |                       |
|            |    |               | \_\_\_\_ |                       |
|            |    |               | \_\_\_\_ |                       |
|            |    |               | \_\_\_\_ |                       |
|            |    |               | \_\_\_\_ |                       |
|            |    |               | \_\_\_\_ |                       |
|            |    |               | \_\_\_\_ |                       |
|            |    |               | \_\_\_\_ |                       |
|            |    |               | \_\_\_\_ |                       |
|            |    |               |          |                       |
|            |    |               | \_\_\_   |                       |
|            |    |               | \_\_\_\_ |                       |
|            |    |               | \_\_\_\_ |                       |
|            |    |               | \_\_\_\_ |                       |
|            |    |               | \_\_\_\_ |                       |
|            |    |               | \_\_\_\_ |                       |
|            |    |               | \_\_\_\_ |                       |
|            |    |               | \_\_\_\_ |                       |
|            |    |               | \_\_\_\_ |                       |
|            |    |               | \_\_\_\_ |                       |
|            |    |               | \_\_\_\_ |                       |
|            |    |               | \_\_\_\_ |                       |
|            |    |               | \_\_\_\_ |                       |
|            |    |               | \_\_\_\_ |                       |
|            |    |               | \_\_\_\_ |                       |
+------------+----+---------------+----------+-----------------------+
| Base       | Cr |               |          |                       |
|            | ew |               |          |                       |
| Month:     | P  |               |          |                       |
|            | os |               |          |                       |
| \_\_\_     | it |               |          |                       |
| \_\_\_\_\_ | io |               |          |                       |
|            | n: |               |          |                       |
|            | □  |               |          |                       |
|            | P  |               |          |                       |
|            | IC |               |          |                       |
|            | □  |               |          |                       |
|            | S  |               |          |                       |
|            | IC |               |          |                       |
|            | □  |               |          |                       |
|            | FE |               |          |                       |
+------------+----+---------------+----------+-----------------------+

  -------------- ----------------- --------------- ---------------- ------------ -------------------
  **AIRCRAFT /                                                                   
  SIMULATOR /                                                                    
  TRAINING                                                                       
  DEVICE**                                                                       

  **AIRCRAFT**                     **SIMULATOR**                    **TRAINING   
                                                                    DEVICE**     

  Make:                            FAA ID #:                        FAA ID #:    

  Model:                           Level:                           Level:       

  Series:                          Type:                            Type:        

  Reg #:                           Model:                           Model:       
  -------------- ----------------- --------------- ---------------- ------------ -------------------

  ------------------------ ---------------------- -----------------------
  **TYPE & RESULTS OF                             
  EVALUATION**                                    

  Type of Evaluation: □    □ Satisfactory □       Temporary Certificate
  135.293 □ 135.297        Unsat. □ Incomplete    Issued: □ Yes □ No

  Date All Events          Base Month Changed: □  Flt / Sim. Evaluation
  completed: / /           Yes □ No               -- Hr. & Min: /

  Comments:                                       

                                                  

                                                  

                                                  

                                                  

                                                  

  Name: (Print)            Signature:             Date:
  ------------------------ ---------------------- -----------------------

**KNOWLEDGE TEST -- REQUIRED TASKS \[135.293 (a)\]**

+----+----+-----+-----+----+------------------+-------------------+
| #  |    | ##  | #   | *  | **Evaluator Name | **Evaluator       |
|  1 |    |  Or | # D | *R | (Print),**       | Signature**       |
| 35 |    | al  | ate | es |                  |                   |
| .2 |    | / W |  Co | ul | **Position       |                   |
| 93 |    | rit | mpl | ts | (FAA/Ck          |                   |
|  R |    | ten | ete | ** | Air/APD/etc.) &  |                   |
| eg |    |     | d ( |    | No.**            |                   |
| ul |    |     | mm/ | ** |                  |                   |
| at |    |     | dd/ | (S |                  |                   |
| or |    |     | yy) | /  |                  |                   |
| y  |    |     |     | U) |                  |                   |
| Re |    |     |     | ** |                  |                   |
| qu |    |     |     |    |                  |                   |
| ir |    |     |     |    |                  |                   |
| em |    |     |     |    |                  |                   |
| en |    |     |     |    |                  |                   |
| ts |    |     |     |    |                  |                   |
+----+----+-----+-----+----+------------------+-------------------+
| #  |    | **N |     |    |                  |                   |
| (a |    | OTE |     |    |                  |                   |
| )  |    | :** |     |    |                  |                   |
| Kn |    | If  |     |    |                  |                   |
| ow |    | sub |     |    |                  |                   |
| le |    | par |     |    |                  |                   |
| dg |    | agr |     |    |                  |                   |
| e  |    | aph |     |    |                  |                   |
| Te |    | 1   |     |    |                  |                   |
| st |    | 35. |     |    |                  |                   |
|    |    | 293 |     |    |                  |                   |
|    |    | (a) |     |    |                  |                   |
|    |    | req |     |    |                  |                   |
|    |    | uir |     |    |                  |                   |
|    |    | eme |     |    |                  |                   |
|    |    | nts |     |    |                  |                   |
|    |    | w   |     |    |                  |                   |
|    |    | ere |     |    |                  |                   |
|    |    | com |     |    |                  |                   |
|    |    | ple |     |    |                  |                   |
|    |    | ted |     |    |                  |                   |
|    |    | by  |     |    |                  |                   |
|    |    | dif |     |    |                  |                   |
|    |    | fer |     |    |                  |                   |
|    |    | ent |     |    |                  |                   |
|    |    | in  |     |    |                  |                   |
|    |    | div |     |    |                  |                   |
|    |    | idu |     |    |                  |                   |
|    |    | als |     |    |                  |                   |
|    |    | or  |     |    |                  |                   |
|    |    | at  |     |    |                  |                   |
|    |    | dif |     |    |                  |                   |
|    |    | fer |     |    |                  |                   |
|    |    | ent |     |    |                  |                   |
|    |    | tim |     |    |                  |                   |
|    |    | es, |     |    |                  |                   |
|    |    | ple |     |    |                  |                   |
|    |    | ase |     |    |                  |                   |
|    |    | co  |     |    |                  |                   |
|    |    | mpl |     |    |                  |                   |
|    |    | ete |     |    |                  |                   |
|    |    | the |     |    |                  |                   |
|    |    | fol |     |    |                  |                   |
|    |    | low |     |    |                  |                   |
|    |    | ing |     |    |                  |                   |
|    |    | s   |     |    |                  |                   |
|    |    | ect |     |    |                  |                   |
|    |    | ion |     |    |                  |                   |
|    |    | i   |     |    |                  |                   |
|    |    | ndi |     |    |                  |                   |
|    |    | cat |     |    |                  |                   |
|    |    | ing |     |    |                  |                   |
|    |    | the |     |    |                  |                   |
|    |    | met |     |    |                  |                   |
|    |    | hod |     |    |                  |                   |
|    |    | of  |     |    |                  |                   |
|    |    | ev  |     |    |                  |                   |
|    |    | alu |     |    |                  |                   |
|    |    | ati |     |    |                  |                   |
|    |    | on, |     |    |                  |                   |
|    |    | da  |     |    |                  |                   |
|    |    | te, |     |    |                  |                   |
|    |    | re  |     |    |                  |                   |
|    |    | sul |     |    |                  |                   |
|    |    | ts, |     |    |                  |                   |
|    |    | and |     |    |                  |                   |
|    |    | the |     |    |                  |                   |
|    |    | eva |     |    |                  |                   |
|    |    | lua |     |    |                  |                   |
|    |    | tor |     |    |                  |                   |
|    |    | who |     |    |                  |                   |
|    |    | con |     |    |                  |                   |
|    |    | duc |     |    |                  |                   |
|    |    | ted |     |    |                  |                   |
|    |    | the |     |    |                  |                   |
|    |    | eve |     |    |                  |                   |
|    |    | nt. |     |    |                  |                   |
+----+----+-----+-----+----+------------------+-------------------+
| #  | #  | #   | / / |    |                  |                   |
|    | (a | □ O |     |    |                  |                   |
|    | )( |  /  |     |    |                  |                   |
|    | 1) | □ W |     |    |                  |                   |
+----+----+-----+-----+----+------------------+-------------------+
| #  | #  | #   | / / |    |                  |                   |
|    | (a | □ O |     |    |                  |                   |
|    | )( |  /  |     |    |                  |                   |
|    | 2) | □ W |     |    |                  |                   |
+----+----+-----+-----+----+------------------+-------------------+
| #  | #  | #   | / / |    |                  |                   |
|    | (a | □ O |     |    |                  |                   |
|    | )( |  /  |     |    |                  |                   |
|    | 3) | □ W |     |    |                  |                   |
+----+----+-----+-----+----+------------------+-------------------+
| #  | #  | #   | / / |    |                  |                   |
|    | (a | □ O |     |    |                  |                   |
|    | )( |  /  |     |    |                  |                   |
|    | 4) | □ W |     |    |                  |                   |
+----+----+-----+-----+----+------------------+-------------------+
| #  | #  | #   | / / |    |                  |                   |
|    | (a | □ O |     |    |                  |                   |
|    | )( |  /  |     |    |                  |                   |
|    | 5) | □ W |     |    |                  |                   |
+----+----+-----+-----+----+------------------+-------------------+
| #  | #  | #   | / / |    |                  |                   |
|    | (a | □ O |     |    |                  |                   |
|    | )( |  /  |     |    |                  |                   |
|    | 6) | □ W |     |    |                  |                   |
+----+----+-----+-----+----+------------------+-------------------+
| #  | #  | #   | / / |    |                  |                   |
|    | (a | □ O |     |    |                  |                   |
|    | )( |  /  |     |    |                  |                   |
|    | 7) | □ W |     |    |                  |                   |
+----+----+-----+-----+----+------------------+-------------------+
| #  | #  | #   | / / |    |                  |                   |
|    | (a | □ O |     |    |                  |                   |
|    | )( |  /  |     |    |                  |                   |
|    | 8) | □ W |     |    |                  |                   |
+----+----+-----+-----+----+------------------+-------------------+
| I  |    |     |     | Da |                  |                   |
| c  |    |     |     | te |                  |                   |
| er |    |     |     |    |                  |                   |
| ti |    |     |     | mm |                  |                   |
| fy |    |     |     | /d |                  |                   |
| th |    |     |     | d/ |                  |                   |
| at |    |     |     | yy |                  |                   |
| t  |    |     |     |    |                  |                   |
| he |    |     |     |    |                  |                   |
| re |    |     |     |    |                  |                   |
| qu |    |     |     |    |                  |                   |
| ir |    |     |     |    |                  |                   |
| em |    |     |     |    |                  |                   |
| en |    |     |     |    |                  |                   |
| ts |    |     |     |    |                  |                   |
| of |    |     |     |    |                  |                   |
| 1  |    |     |     |    |                  |                   |
| 35 |    |     |     |    |                  |                   |
| .2 |    |     |     |    |                  |                   |
| 93 |    |     |     |    |                  |                   |
| (  |    |     |     |    |                  |                   |
| a) |    |     |     |    |                  |                   |
| (1 |    |     |     |    |                  |                   |
| -- |    |     |     |    |                  |                   |
| 8) |    |     |     |    |                  |                   |
| ha |    |     |     |    |                  |                   |
| ve |    |     |     |    |                  |                   |
| be |    |     |     |    |                  |                   |
| en |    |     |     |    |                  |                   |
| [s |    |     |     |    |                  |                   |
| at |    |     |     |    |                  |                   |
| is |    |     |     |    |                  |                   |
| fa |    |     |     |    |                  |                   |
| ct |    |     |     |    |                  |                   |
| or |    |     |     |    |                  |                   |
| il |    |     |     |    |                  |                   |
| y] |    |     |     |    |                  |                   |
| {. |    |     |     |    |                  |                   |
| un |    |     |     |    |                  |                   |
| de |    |     |     |    |                  |                   |
| rl |    |     |     |    |                  |                   |
| in |    |     |     |    |                  |                   |
| e} |    |     |     |    |                  |                   |
| c  |    |     |     |    |                  |                   |
| om |    |     |     |    |                  |                   |
| pl |    |     |     |    |                  |                   |
| et |    |     |     |    |                  |                   |
| ed |    |     |     |    |                  |                   |
| by |    |     |     |    |                  |                   |
| t  |    |     |     |    |                  |                   |
| he |    |     |     |    |                  |                   |
| ap |    |     |     |    |                  |                   |
| pl |    |     |     |    |                  |                   |
| ic |    |     |     |    |                  |                   |
| an |    |     |     |    |                  |                   |
| t: |    |     |     |    |                  |                   |
+----+----+-----+-----+----+------------------+-------------------+
|    |    |     |     | /  |                  |                   |
|    |    |     |     | /  |                  |                   |
+----+----+-----+-----+----+------------------+-------------------+
| T  |    |     |     | Da |                  |                   |
| he |    |     |     | te |                  |                   |
| r  |    |     |     |    |                  |                   |
| es |    |     |     | mm |                  |                   |
| ul |    |     |     | /d |                  |                   |
| ts |    |     |     | d/ |                  |                   |
| of |    |     |     | yy |                  |                   |
| t  |    |     |     |    |                  |                   |
| he |    |     |     |    |                  |                   |
| ev |    |     |     |    |                  |                   |
| al |    |     |     |    |                  |                   |
| ua |    |     |     |    |                  |                   |
| ti |    |     |     |    |                  |                   |
| on |    |     |     |    |                  |                   |
| a  |    |     |     |    |                  |                   |
| re |    |     |     |    |                  |                   |
| [u |    |     |     |    |                  |                   |
| ns |    |     |     |    |                  |                   |
| at |    |     |     |    |                  |                   |
| is |    |     |     |    |                  |                   |
| fa |    |     |     |    |                  |                   |
| ct |    |     |     |    |                  |                   |
| or |    |     |     |    |                  |                   |
| y] |    |     |     |    |                  |                   |
| {. |    |     |     |    |                  |                   |
| un |    |     |     |    |                  |                   |
| de |    |     |     |    |                  |                   |
| rl |    |     |     |    |                  |                   |
| in |    |     |     |    |                  |                   |
| e} |    |     |     |    |                  |                   |
| a  |    |     |     |    |                  |                   |
| nd |    |     |     |    |                  |                   |
| t  |    |     |     |    |                  |                   |
| he |    |     |     |    |                  |                   |
| a  |    |     |     |    |                  |                   |
| pp |    |     |     |    |                  |                   |
| li |    |     |     |    |                  |                   |
| ca |    |     |     |    |                  |                   |
| nt |    |     |     |    |                  |                   |
| h  |    |     |     |    |                  |                   |
| as |    |     |     |    |                  |                   |
| be |    |     |     |    |                  |                   |
| en |    |     |     |    |                  |                   |
| n  |    |     |     |    |                  |                   |
| ot |    |     |     |    |                  |                   |
| if |    |     |     |    |                  |                   |
| ie |    |     |     |    |                  |                   |
| d. |    |     |     |    |                  |                   |
+----+----+-----+-----+----+------------------+-------------------+
|    |    |     |     | /  |                  |                   |
|    |    |     |     | /  |                  |                   |
+----+----+-----+-----+----+------------------+-------------------+

**PRACTICAL TEST / CHECK -- REQUIRED TASKS (FIXED WING)**

+---+-------------------+------+------+------+------------------------+
| * |                   |      |      |      |                        |
| * |                   |      |      |      |                        |
| G |                   |      |      |      |                        |
| R |                   |      |      |      |                        |
| A |                   |      |      |      |                        |
| D |                   |      |      |      |                        |
| I |                   |      |      |      |                        |
| N |                   |      |      |      |                        |
| G |                   |      |      |      |                        |
| C |                   |      |      |      |                        |
| R |                   |      |      |      |                        |
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| I |                   |      |      |      |                        |
| A |                   |      |      |      |                        |
| * |                   |      |      |      |                        |
| * |                   |      |      |      |                        |
+---+-------------------+------+------+------+------------------------+
| * |                   |      |      |      |                        |
| * |                   |      |      |      |                        |
| [ |                   |      |      |      |                        |
| S |                   |      |      |      |                        |
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| e |                   |      |      |      |                        |
| r |                   |      |      |      |                        |
| l |                   |      |      |      |                        |
| i |                   |      |      |      |                        |
| n |                   |      |      |      |                        |
| e |                   |      |      |      |                        |
| } |                   |      |      |      |                        |
| - |                   |      |      |      |                        |
| - |                   |      |      |      |                        |
| * |                   |      |      |      |                        |
| * |                   |      |      |      |                        |
| W |                   |      |      |      |                        |
| a |                   |      |      |      |                        |
| i |                   |      |      |      |                        |
| v |                   |      |      |      |                        |
| e |                   |      |      |      |                        |
| d |                   |      |      |      |                        |
| * |                   |      |      |      |                        |
| * |                   |      |      |      |                        |
| [ |                   |      |      |      |                        |
| N |                   |      |      |      |                        |
| / |                   |      |      |      |                        |
| A |                   |      |      |      |                        |
| ] |                   |      |      |      |                        |
| { |                   |      |      |      |                        |
| . |                   |      |      |      |                        |
| u |                   |      |      |      |                        |
| n |                   |      |      |      |                        |
| d |                   |      |      |      |                        |
| e |                   |      |      |      |                        |
| r |                   |      |      |      |                        |
| l |                   |      |      |      |                        |
| i |                   |      |      |      |                        |
| n |                   |      |      |      |                        |
| e |                   |      |      |      |                        |
| } |                   |      |      |      |                        |
| - |                   |      |      |      |                        |
| * |                   |      |      |      |                        |
| * |                   |      |      |      |                        |
| N |                   |      |      |      |                        |
| o |                   |      |      |      |                        |
| t |                   |      |      |      |                        |
| A |                   |      |      |      |                        |
| p |                   |      |      |      |                        |
| p |                   |      |      |      |                        |
| l |                   |      |      |      |                        |
| i |                   |      |      |      |                        |
| c |                   |      |      |      |                        |
| a |                   |      |      |      |                        |
| b |                   |      |      |      |                        |
| l |                   |      |      |      |                        |
| e |                   |      |      |      |                        |
+---+-------------------+------+------+------+------------------------+
| # |                   | **   | ***  | ***A | ***Remarks***          |
|   |                   | *Air | Simu | ddit |                        |
| * |                   | craf | lato | iona |                        |
| T |                   | t*** | r*** | l*** |                        |
| A |                   |      |      |      |                        |
| S |                   |      |      | **   |                        |
| K |                   |      |      | *Tra |                        |
| S |                   |      |      | inin |                        |
| * |                   |      |      | g*** |                        |
|   |                   |      |      |      |                        |
|   |                   |      |      | **   |                        |
|   |                   |      |      | *Acc |                        |
|   |                   |      |      | ompl |                        |
|   |                   |      |      | ishe |                        |
|   |                   |      |      | d*** |                        |
+---+-------------------+------+------+------+------------------------+
| > | Equipment         |      |      |      |                        |
|   | Examination       |      |      |      |                        |
| * |                   |      |      |      |                        |
| * |                   |      |      |      |                        |
| P |                   |      |      |      |                        |
| r |                   |      |      |      |                        |
| e |                   |      |      |      |                        |
| f |                   |      |      |      |                        |
| l |                   |      |      |      |                        |
| i |                   |      |      |      |                        |
| g |                   |      |      |      |                        |
| h |                   |      |      |      |                        |
| t |                   |      |      |      |                        |
| * |                   |      |      |      |                        |
| * |                   |      |      |      |                        |
+---+-------------------+------+------+------+------------------------+
|   | Preflight         |      |      |      |                        |
|   | Inspection        |      |      |      |                        |
+---+-------------------+------+------+------+------------------------+
|   | Taxiing           |      |      |      |                        |
+---+-------------------+------+------+------+------------------------+
|   | Pre-Takeoff       |      |      |      |                        |
|   | Checks            |      |      |      |                        |
+---+-------------------+------+------+------+------------------------+
|   |                   |      |      |      |                        |
+---+-------------------+------+------+------+------------------------+
| > | Normal /          |      |      |      |                        |
|   | Crosswind         |      |      |      |                        |
| * |                   |      |      |      |                        |
| * |                   |      |      |      |                        |
| T |                   |      |      |      |                        |
| a |                   |      |      |      |                        |
| k |                   |      |      |      |                        |
| e |                   |      |      |      |                        |
| o |                   |      |      |      |                        |
| f |                   |      |      |      |                        |
| f |                   |      |      |      |                        |
| * |                   |      |      |      |                        |
| * |                   |      |      |      |                        |
+---+-------------------+------+------+------+------------------------+
|   | Instrument (VIS:  |      |      |      |                        |
|   | )                 |      |      |      |                        |
+---+-------------------+------+------+------+------------------------+
|   | With Powerplant   |      |      |      |                        |
|   | Failure           |      |      |      |                        |
+---+-------------------+------+------+------+------------------------+
|   | Rejected Takeoff  |      |      |      |                        |
+---+-------------------+------+------+------+------------------------+
|   |                   |      |      |      |                        |
+---+-------------------+------+------+------+------------------------+
| > | Steep Turns       |      |      |      |                        |
|   |                   |      |      |      |                        |
| * |                   |      |      |      |                        |
| * |                   |      |      |      |                        |
| I |                   |      |      |      |                        |
| n |                   |      |      |      |                        |
| f |                   |      |      |      |                        |
| l |                   |      |      |      |                        |
| i |                   |      |      |      |                        |
| g |                   |      |      |      |                        |
| h |                   |      |      |      |                        |
| t |                   |      |      |      |                        |
| * |                   |      |      |      |                        |
| * |                   |      |      |      |                        |
| > |                   |      |      |      |                        |
| > |                   |      |      |      |                        |
|   |                   |      |      |      |                        |
| * |                   |      |      |      |                        |
| * |                   |      |      |      |                        |
| M |                   |      |      |      |                        |
| a |                   |      |      |      |                        |
| n |                   |      |      |      |                        |
| e |                   |      |      |      |                        |
| u |                   |      |      |      |                        |
| v |                   |      |      |      |                        |
| e |                   |      |      |      |                        |
| r |                   |      |      |      |                        |
| s |                   |      |      |      |                        |
| * |                   |      |      |      |                        |
| * |                   |      |      |      |                        |
+---+-------------------+------+------+------+------------------------+
|   | Approaches to     |      |      |      |                        |
|   | Stalls            |      |      |      |                        |
+---+-------------------+------+------+------+------------------------+
|   | Unusual Attitudes |      |      |      |                        |
+---+-------------------+------+------+------+------------------------+
|   | Specific Flight   |      |      |      |                        |
|   | Characteristics   |      |      |      |                        |
+---+-------------------+------+------+------+------------------------+
|   | Powerplant        |      |      |      |                        |
|   | Failure           |      |      |      |                        |
+---+-------------------+------+------+------+------------------------+
|   |                   |      |      |      |                        |
+---+-------------------+------+------+------+------------------------+

**Continued on Page 3**

**Continued From Page 2**

+---+-------------------+------+------+------+---+---------------------+
| # |                   | **   | ***  | ***A | * |                     |
|   |                   | *Air | Simu | ddit | * |                     |
| * |                   | craf | lato | iona | * |                     |
| T |                   | t*** | r*** | l*** | R |                     |
| A |                   |      |      |      | e |                     |
| S |                   |      |      | **   | m |                     |
| K |                   |      |      | *Tra | a |                     |
| S |                   |      |      | inin | r |                     |
|   |                   |      |      | g*** | k |                     |
| ( |                   |      |      |      | s |                     |
| C |                   |      |      | **   | * |                     |
| o |                   |      |      | *Acc | * |                     |
| n |                   |      |      | ompl | * |                     |
| t |                   |      |      | ishe |   |                     |
| i |                   |      |      | d*** |   |                     |
| n |                   |      |      |      |   |                     |
| u |                   |      |      |      |   |                     |
| e |                   |      |      |      |   |                     |
| d |                   |      |      |      |   |                     |
| ) |                   |      |      |      |   |                     |
| * |                   |      |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
| > | Normal /          |      |      |      |   |                     |
|   | Crosswind         |      |      |      |   |                     |
| * |                   |      |      |      |   |                     |
| * |                   |      |      |      |   |                     |
| L |                   |      |      |      |   |                     |
| a |                   |      |      |      |   |                     |
| n |                   |      |      |      |   |                     |
| d |                   |      |      |      |   |                     |
| i |                   |      |      |      |   |                     |
| n |                   |      |      |      |   |                     |
| g |                   |      |      |      |   |                     |
| * |                   |      |      |      |   |                     |
| * |                   |      |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
|   | From an ILS       |      |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
|   | With              |      |      |      |   |                     |
|   | Powerplant(s)     |      |      |      |   |                     |
|   | Failure           |      |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
|   | Rejected Landing  |      |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
|   | Zero or           |      |      |      |   |                     |
|   | Non-Standard Flap |      |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
|   | From Circling     |      |      |      |   |                     |
|   | Approach          |      |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
|   |                   |      |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
| > | Normal / Abnormal |      |      |      |   |                     |
|   | Procedures:       |      |      |      |   |                     |
| * |                   |      |      |      |   |                     |
| * |                   |      |      |      |   |                     |
| A |                   |      |      |      |   |                     |
| i |                   |      |      |      |   |                     |
| r |                   |      |      |      |   |                     |
| c |                   |      |      |      |   |                     |
| r |                   |      |      |      |   |                     |
| a |                   |      |      |      |   |                     |
| f |                   |      |      |      |   |                     |
| t |                   |      |      |      |   |                     |
| > |                   |      |      |      |   |                     |
|   |                   |      |      |      |   |                     |
| P |                   |      |      |      |   |                     |
| r |                   |      |      |      |   |                     |
| o |                   |      |      |      |   |                     |
| c |                   |      |      |      |   |                     |
| e |                   |      |      |      |   |                     |
| d |                   |      |      |      |   |                     |
| u |                   |      |      |      |   |                     |
| r |                   |      |      |      |   |                     |
| e |                   |      |      |      |   |                     |
| s |                   |      |      |      |   |                     |
| * |                   |      |      |      |   |                     |
| * |                   |      |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
|   |                   |      |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
|   |                   |      |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
|   | Emergency         |      |      |      |   |                     |
|   | Procedures:       |      |      |      |   |                     |
|   | *(Specify)*       |      |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
|   |                   |      |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
|   |                   |      |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
| > | Departure         |      |      |      |   |                     |
|   | Procedures        |      |      |      |   |                     |
| * |                   |      |      |      |   |                     |
| * |                   |      |      |      |   |                     |
| I |                   |      |      |      |   |                     |
| n |                   |      |      |      |   |                     |
| s |                   |      |      |      |   |                     |
| t |                   |      |      |      |   |                     |
| r |                   |      |      |      |   |                     |
| u |                   |      |      |      |   |                     |
| m |                   |      |      |      |   |                     |
| e |                   |      |      |      |   |                     |
| n |                   |      |      |      |   |                     |
| t |                   |      |      |      |   |                     |
| > |                   |      |      |      |   |                     |
|   |                   |      |      |      |   |                     |
| P |                   |      |      |      |   |                     |
| r |                   |      |      |      |   |                     |
| o |                   |      |      |      |   |                     |
| c |                   |      |      |      |   |                     |
| e |                   |      |      |      |   |                     |
| d |                   |      |      |      |   |                     |
| u |                   |      |      |      |   |                     |
| r |                   |      |      |      |   |                     |
| e |                   |      |      |      |   |                     |
| s |                   |      |      |      |   |                     |
| * |                   |      |      |      |   |                     |
| * |                   |      |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
|   | Holding           |      |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
|   | Arrival           |      |      |      |   |                     |
|   | Procedures (FMS)  |      |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
|   | ILS Approach -    |      |      |      |   |                     |
|   | Normal:           |      |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
|   | > One Powerplant  |      |      |      |   |                     |
|   | > Inoperative     |      |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
|   | Other Instrument  |      |      |      |   |                     |
|   | Approaches        |      |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
|   | > NDB             |      |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
|   | > VOR/LOC/LDA     |      |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
|   | > LOC-BC          |      |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
|   | > RNAV/ GPS       |      |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
|   | > Other           |      |      |      |   |                     |
|   | > *(Specify)*     |      |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
|   | Circling Approach |      |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
|   | Missed Approaches |      |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
|   | > One Powerplant  |      |      |      |   |                     |
|   | > Inoperative     |      |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
|   | > ILS             |      |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
|   | Comm./Nav.        |      |      |      |   |                     |
|   | Procedures        |      |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
|   | Use of Auto-Pilot |      |      |      |   |                     |
|   | / Automation      |      |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
|   |                   |      |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
| > | Judgment          |      |      |      |   |                     |
|   |                   |      |      |      |   |                     |
| * |                   |      |      |      |   |                     |
| * |                   |      |      |      |   |                     |
| G |                   |      |      |      |   |                     |
| e |                   |      |      |      |   |                     |
| n |                   |      |      |      |   |                     |
| e |                   |      |      |      |   |                     |
| r |                   |      |      |      |   |                     |
| a |                   |      |      |      |   |                     |
| l |                   |      |      |      |   |                     |
| * |                   |      |      |      |   |                     |
| * |                   |      |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
|   | Crew              |      |      |      |   |                     |
|   | Coordination/CRM  |      |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
|   | Demonstrated Use  |      |      |      |   |                     |
|   | of Autopilot in   |      |      |      |   |                     |
|   | lieu              |      |      |      |   |                     |
|   |                   |      |      |      |   |                     |
|   | of SIC            |      |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
|   | Other             |      |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
|   |                   |      |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
| I |                   | Date | **E  |      |   | **Evaluator         |
| c |                   |      | valu |      |   | Signature**         |
| e |                   | (m   | ator |      |   |                     |
| r |                   | m/dd | Name |      |   |                     |
| t |                   | /yy) | (P   |      |   |                     |
| i |                   |      | rint |      |   |                     |
| f |                   | / /  | ),** |      |   |                     |
| y |                   |      |      |      |   |                     |
| t |                   |      | **   |      |   |                     |
| h |                   |      | Posi |      |   |                     |
| a |                   |      | tion |      |   |                     |
| t |                   |      | (FA  |      |   |                     |
| t |                   |      | A/Ck |      |   |                     |
| h |                   |      | A    |      |   |                     |
| e |                   |      | ir/A |      |   |                     |
| c |                   |      | PD/e |      |   |                     |
| o |                   |      | tc.) |      |   |                     |
| m |                   |      | &    |      |   |                     |
| p |                   |      | N    |      |   |                     |
| e |                   |      | o.** |      |   |                     |
| t |                   |      |      |      |   |                     |
| e |                   |      |      |      |   |                     |
| n |                   |      |      |      |   |                     |
| c |                   |      |      |      |   |                     |
| y |                   |      |      |      |   |                     |
| c |                   |      |      |      |   |                     |
| h |                   |      |      |      |   |                     |
| e |                   |      |      |      |   |                     |
| c |                   |      |      |      |   |                     |
| k |                   |      |      |      |   |                     |
| r |                   |      |      |      |   |                     |
| e |                   |      |      |      |   |                     |
| q |                   |      |      |      |   |                     |
| u |                   |      |      |      |   |                     |
| i |                   |      |      |      |   |                     |
| r |                   |      |      |      |   |                     |
| e |                   |      |      |      |   |                     |
| m |                   |      |      |      |   |                     |
| e |                   |      |      |      |   |                     |
| n |                   |      |      |      |   |                     |
| t |                   |      |      |      |   |                     |
| s |                   |      |      |      |   |                     |
| o |                   |      |      |      |   |                     |
| f |                   |      |      |      |   |                     |
| 1 |                   |      |      |      |   |                     |
| 3 |                   |      |      |      |   |                     |
| 5 |                   |      |      |      |   |                     |
| . |                   |      |      |      |   |                     |
| 2 |                   |      |      |      |   |                     |
| 9 |                   |      |      |      |   |                     |
| 3 |                   |      |      |      |   |                     |
| ( |                   |      |      |      |   |                     |
| b |                   |      |      |      |   |                     |
| ) |                   |      |      |      |   |                     |
| a |                   |      |      |      |   |                     |
| n |                   |      |      |      |   |                     |
| d |                   |      |      |      |   |                     |
| 1 |                   |      |      |      |   |                     |
| 3 |                   |      |      |      |   |                     |
| 5 |                   |      |      |      |   |                     |
| . |                   |      |      |      |   |                     |
| 2 |                   |      |      |      |   |                     |
| 9 |                   |      |      |      |   |                     |
| 7 |                   |      |      |      |   |                     |
| h |                   |      |      |      |   |                     |
| a |                   |      |      |      |   |                     |
| v |                   |      |      |      |   |                     |
| e |                   |      |      |      |   |                     |
| b |                   |      |      |      |   |                     |
| e |                   |      |      |      |   |                     |
| e |                   |      |      |      |   |                     |
| n |                   |      |      |      |   |                     |
| [ |                   |      |      |      |   |                     |
| s |                   |      |      |      |   |                     |
| a |                   |      |      |      |   |                     |
| t |                   |      |      |      |   |                     |
| i |                   |      |      |      |   |                     |
| s |                   |      |      |      |   |                     |
| f |                   |      |      |      |   |                     |
| a |                   |      |      |      |   |                     |
| c |                   |      |      |      |   |                     |
| t |                   |      |      |      |   |                     |
| o |                   |      |      |      |   |                     |
| r |                   |      |      |      |   |                     |
| i |                   |      |      |      |   |                     |
| l |                   |      |      |      |   |                     |
| y |                   |      |      |      |   |                     |
| ] |                   |      |      |      |   |                     |
| { |                   |      |      |      |   |                     |
| . |                   |      |      |      |   |                     |
| u |                   |      |      |      |   |                     |
| n |                   |      |      |      |   |                     |
| d |                   |      |      |      |   |                     |
| e |                   |      |      |      |   |                     |
| r |                   |      |      |      |   |                     |
| l |                   |      |      |      |   |                     |
| i |                   |      |      |      |   |                     |
| n |                   |      |      |      |   |                     |
| e |                   |      |      |      |   |                     |
| } |                   |      |      |      |   |                     |
| c |                   |      |      |      |   |                     |
| o |                   |      |      |      |   |                     |
| m |                   |      |      |      |   |                     |
| p |                   |      |      |      |   |                     |
| l |                   |      |      |      |   |                     |
| e |                   |      |      |      |   |                     |
| t |                   |      |      |      |   |                     |
| e |                   |      |      |      |   |                     |
| d |                   |      |      |      |   |                     |
| b |                   |      |      |      |   |                     |
| y |                   |      |      |      |   |                     |
| t |                   |      |      |      |   |                     |
| h |                   |      |      |      |   |                     |
| e |                   |      |      |      |   |                     |
| a |                   |      |      |      |   |                     |
| p |                   |      |      |      |   |                     |
| p |                   |      |      |      |   |                     |
| l |                   |      |      |      |   |                     |
| i |                   |      |      |      |   |                     |
| c |                   |      |      |      |   |                     |
| a |                   |      |      |      |   |                     |
| n |                   |      |      |      |   |                     |
| t |                   |      |      |      |   |                     |
| : |                   |      |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
|   |                   | / /  |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
| T |                   | Date |      |      |   |                     |
| h |                   |      |      |      |   |                     |
| e |                   | (m   |      |      |   |                     |
| r |                   | m/dd |      |      |   |                     |
| e |                   | /yy) |      |      |   |                     |
| s |                   |      |      |      |   |                     |
| u |                   |      |      |      |   |                     |
| l |                   |      |      |      |   |                     |
| t |                   |      |      |      |   |                     |
| s |                   |      |      |      |   |                     |
| o |                   |      |      |      |   |                     |
| f |                   |      |      |      |   |                     |
| t |                   |      |      |      |   |                     |
| h |                   |      |      |      |   |                     |
| e |                   |      |      |      |   |                     |
| e |                   |      |      |      |   |                     |
| v |                   |      |      |      |   |                     |
| a |                   |      |      |      |   |                     |
| l |                   |      |      |      |   |                     |
| u |                   |      |      |      |   |                     |
| a |                   |      |      |      |   |                     |
| t |                   |      |      |      |   |                     |
| i |                   |      |      |      |   |                     |
| o |                   |      |      |      |   |                     |
| n |                   |      |      |      |   |                     |
| a |                   |      |      |      |   |                     |
| r |                   |      |      |      |   |                     |
| e |                   |      |      |      |   |                     |
| [ |                   |      |      |      |   |                     |
| u |                   |      |      |      |   |                     |
| n |                   |      |      |      |   |                     |
| s |                   |      |      |      |   |                     |
| a |                   |      |      |      |   |                     |
| t |                   |      |      |      |   |                     |
| i |                   |      |      |      |   |                     |
| s |                   |      |      |      |   |                     |
| f |                   |      |      |      |   |                     |
| a |                   |      |      |      |   |                     |
| c |                   |      |      |      |   |                     |
| t |                   |      |      |      |   |                     |
| o |                   |      |      |      |   |                     |
| r |                   |      |      |      |   |                     |
| y |                   |      |      |      |   |                     |
| ] |                   |      |      |      |   |                     |
| { |                   |      |      |      |   |                     |
| . |                   |      |      |      |   |                     |
| u |                   |      |      |      |   |                     |
| n |                   |      |      |      |   |                     |
| d |                   |      |      |      |   |                     |
| e |                   |      |      |      |   |                     |
| r |                   |      |      |      |   |                     |
| l |                   |      |      |      |   |                     |
| i |                   |      |      |      |   |                     |
| n |                   |      |      |      |   |                     |
| e |                   |      |      |      |   |                     |
| } |                   |      |      |      |   |                     |
| a |                   |      |      |      |   |                     |
| n |                   |      |      |      |   |                     |
| d |                   |      |      |      |   |                     |
| t |                   |      |      |      |   |                     |
| h |                   |      |      |      |   |                     |
| e |                   |      |      |      |   |                     |
| a |                   |      |      |      |   |                     |
| p |                   |      |      |      |   |                     |
| p |                   |      |      |      |   |                     |
| l |                   |      |      |      |   |                     |
| i |                   |      |      |      |   |                     |
| c |                   |      |      |      |   |                     |
| a |                   |      |      |      |   |                     |
| n |                   |      |      |      |   |                     |
| t |                   |      |      |      |   |                     |
| h |                   |      |      |      |   |                     |
| a |                   |      |      |      |   |                     |
| s |                   |      |      |      |   |                     |
| b |                   |      |      |      |   |                     |
| e |                   |      |      |      |   |                     |
| e |                   |      |      |      |   |                     |
| n |                   |      |      |      |   |                     |
| n |                   |      |      |      |   |                     |
| o |                   |      |      |      |   |                     |
| t |                   |      |      |      |   |                     |
| i |                   |      |      |      |   |                     |
| f |                   |      |      |      |   |                     |
| i |                   |      |      |      |   |                     |
| e |                   |      |      |      |   |                     |
| d |                   |      |      |      |   |                     |
| . |                   |      |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
|   |                   | / /  |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+

**PRACTICAL TEST / CHECK -- REQUIRED TASKS (HELICOPTER)**

+---+-------------------+------+------+------+---+---------------------+
| # |                   | **   | ***  | ***A | * |                     |
|   |                   | Heli | Simu | ddit | * |                     |
| * |                   | copt | lato | iona | * |                     |
| T |                   | er** | r*** | l*** | R |                     |
| A |                   |      |      |      | e |                     |
| S |                   |      |      | **   | m |                     |
| K |                   |      |      | *Tra | a |                     |
| S |                   |      |      | inin | r |                     |
|   |                   |      |      | g*** | k |                     |
| ( |                   |      |      |      | s |                     |
| H |                   |      |      | **   | * |                     |
| e |                   |      |      | *Acc | * |                     |
| l |                   |      |      | ompl | * |                     |
| i |                   |      |      | ishe |   |                     |
| c |                   |      |      | d*** |   |                     |
| o |                   |      |      |      |   |                     |
| p |                   |      |      |      |   |                     |
| t |                   |      |      |      |   |                     |
| e |                   |      |      |      |   |                     |
| r |                   |      |      |      |   |                     |
| ) |                   |      |      |      |   |                     |
| * |                   |      |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
| > | Ground and/or Air |      |      |      |   |                     |
|   | Taxi              |      |      |      |   |                     |
| * |                   |      |      |      |   |                     |
| * |                   |      |      |      |   |                     |
| H |                   |      |      |      |   |                     |
| e |                   |      |      |      |   |                     |
| l |                   |      |      |      |   |                     |
| i |                   |      |      |      |   |                     |
| c |                   |      |      |      |   |                     |
| o |                   |      |      |      |   |                     |
| p |                   |      |      |      |   |                     |
| t |                   |      |      |      |   |                     |
| e |                   |      |      |      |   |                     |
| r |                   |      |      |      |   |                     |
| * |                   |      |      |      |   |                     |
| * |                   |      |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
|   | Hover Maneuvers   |      |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
|   | Normal /          |      |      |      |   |                     |
|   | Crosswind Takeoff |      |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
|   | High Altitude     |      |      |      |   |                     |
|   | Takeoff and       |      |      |      |   |                     |
|   | Landing           |      |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
|   | Engine Failure    |      |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
|   | Autorotation      |      |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
|   | Autorotation from |      |      |      |   |                     |
|   | Hover             |      |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
|   | Confined Area     |      |      |      |   |                     |
|   | Operations        |      |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
|   | Slope Operations  |      |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
|   | Pinnacle          |      |      |      |   |                     |
|   | Operations        |      |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
|   | Tail Rotor        |      |      |      |   |                     |
|   | Failure           |      |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
|   | Settling with     |      |      |      |   |                     |
|   | Power             |      |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
|   | Normal /          |      |      |      |   |                     |
|   | Crosswind Landing |      |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
|   | Single Engine     |      |      |      |   |                     |
|   | Operations        |      |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
|   |                   |      |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
|   |                   |      |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
| I |                   | Date | **E  |      |   | **Evaluator         |
| c |                   |      | valu |      |   | Signature**         |
| e |                   | (m   | ator |      |   |                     |
| r |                   | m/dd | Name |      |   |                     |
| t |                   | /yy) | (P   |      |   |                     |
| i |                   |      | rint |      |   |                     |
| f |                   | / /  | ),** |      |   |                     |
| y |                   |      |      |      |   |                     |
| t |                   |      | **   |      |   |                     |
| h |                   |      | Posi |      |   |                     |
| a |                   |      | tion |      |   |                     |
| t |                   |      | (FA  |      |   |                     |
| t |                   |      | A/Ck |      |   |                     |
| h |                   |      | A    |      |   |                     |
| e |                   |      | ir/A |      |   |                     |
| c |                   |      | PD/e |      |   |                     |
| o |                   |      | tc.) |      |   |                     |
| m |                   |      | &    |      |   |                     |
| p |                   |      | N    |      |   |                     |
| e |                   |      | o.** |      |   |                     |
| t |                   |      |      |      |   |                     |
| e |                   |      |      |      |   |                     |
| n |                   |      |      |      |   |                     |
| c |                   |      |      |      |   |                     |
| y |                   |      |      |      |   |                     |
| c |                   |      |      |      |   |                     |
| h |                   |      |      |      |   |                     |
| e |                   |      |      |      |   |                     |
| c |                   |      |      |      |   |                     |
| k |                   |      |      |      |   |                     |
| r |                   |      |      |      |   |                     |
| e |                   |      |      |      |   |                     |
| q |                   |      |      |      |   |                     |
| u |                   |      |      |      |   |                     |
| i |                   |      |      |      |   |                     |
| r |                   |      |      |      |   |                     |
| e |                   |      |      |      |   |                     |
| m |                   |      |      |      |   |                     |
| e |                   |      |      |      |   |                     |
| n |                   |      |      |      |   |                     |
| t |                   |      |      |      |   |                     |
| s |                   |      |      |      |   |                     |
| o |                   |      |      |      |   |                     |
| f |                   |      |      |      |   |                     |
| 1 |                   |      |      |      |   |                     |
| 3 |                   |      |      |      |   |                     |
| 5 |                   |      |      |      |   |                     |
| . |                   |      |      |      |   |                     |
| 2 |                   |      |      |      |   |                     |
| 9 |                   |      |      |      |   |                     |
| 3 |                   |      |      |      |   |                     |
| ( |                   |      |      |      |   |                     |
| b |                   |      |      |      |   |                     |
| ) |                   |      |      |      |   |                     |
| a |                   |      |      |      |   |                     |
| n |                   |      |      |      |   |                     |
| d |                   |      |      |      |   |                     |
| 1 |                   |      |      |      |   |                     |
| 3 |                   |      |      |      |   |                     |
| 5 |                   |      |      |      |   |                     |
| . |                   |      |      |      |   |                     |
| 2 |                   |      |      |      |   |                     |
| 9 |                   |      |      |      |   |                     |
| 7 |                   |      |      |      |   |                     |
| h |                   |      |      |      |   |                     |
| a |                   |      |      |      |   |                     |
| v |                   |      |      |      |   |                     |
| e |                   |      |      |      |   |                     |
| b |                   |      |      |      |   |                     |
| e |                   |      |      |      |   |                     |
| e |                   |      |      |      |   |                     |
| n |                   |      |      |      |   |                     |
| [ |                   |      |      |      |   |                     |
| s |                   |      |      |      |   |                     |
| a |                   |      |      |      |   |                     |
| t |                   |      |      |      |   |                     |
| i |                   |      |      |      |   |                     |
| s |                   |      |      |      |   |                     |
| f |                   |      |      |      |   |                     |
| a |                   |      |      |      |   |                     |
| c |                   |      |      |      |   |                     |
| t |                   |      |      |      |   |                     |
| o |                   |      |      |      |   |                     |
| r |                   |      |      |      |   |                     |
| i |                   |      |      |      |   |                     |
| l |                   |      |      |      |   |                     |
| y |                   |      |      |      |   |                     |
| ] |                   |      |      |      |   |                     |
| { |                   |      |      |      |   |                     |
| . |                   |      |      |      |   |                     |
| u |                   |      |      |      |   |                     |
| n |                   |      |      |      |   |                     |
| d |                   |      |      |      |   |                     |
| e |                   |      |      |      |   |                     |
| r |                   |      |      |      |   |                     |
| l |                   |      |      |      |   |                     |
| i |                   |      |      |      |   |                     |
| n |                   |      |      |      |   |                     |
| e |                   |      |      |      |   |                     |
| } |                   |      |      |      |   |                     |
| c |                   |      |      |      |   |                     |
| o |                   |      |      |      |   |                     |
| m |                   |      |      |      |   |                     |
| p |                   |      |      |      |   |                     |
| l |                   |      |      |      |   |                     |
| e |                   |      |      |      |   |                     |
| t |                   |      |      |      |   |                     |
| e |                   |      |      |      |   |                     |
| d |                   |      |      |      |   |                     |
| b |                   |      |      |      |   |                     |
| y |                   |      |      |      |   |                     |
| t |                   |      |      |      |   |                     |
| h |                   |      |      |      |   |                     |
| e |                   |      |      |      |   |                     |
| a |                   |      |      |      |   |                     |
| p |                   |      |      |      |   |                     |
| p |                   |      |      |      |   |                     |
| l |                   |      |      |      |   |                     |
| i |                   |      |      |      |   |                     |
| c |                   |      |      |      |   |                     |
| a |                   |      |      |      |   |                     |
| n |                   |      |      |      |   |                     |
| t |                   |      |      |      |   |                     |
| . |                   |      |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
|   |                   | / /  |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
| T |                   | Date |      |      |   |                     |
| h |                   |      |      |      |   |                     |
| e |                   | (m   |      |      |   |                     |
| r |                   | m/dd |      |      |   |                     |
| e |                   | /yy) |      |      |   |                     |
| s |                   |      |      |      |   |                     |
| u |                   |      |      |      |   |                     |
| l |                   |      |      |      |   |                     |
| t |                   |      |      |      |   |                     |
| s |                   |      |      |      |   |                     |
| o |                   |      |      |      |   |                     |
| f |                   |      |      |      |   |                     |
| t |                   |      |      |      |   |                     |
| h |                   |      |      |      |   |                     |
| e |                   |      |      |      |   |                     |
| e |                   |      |      |      |   |                     |
| v |                   |      |      |      |   |                     |
| a |                   |      |      |      |   |                     |
| l |                   |      |      |      |   |                     |
| u |                   |      |      |      |   |                     |
| a |                   |      |      |      |   |                     |
| t |                   |      |      |      |   |                     |
| i |                   |      |      |      |   |                     |
| o |                   |      |      |      |   |                     |
| n |                   |      |      |      |   |                     |
| a |                   |      |      |      |   |                     |
| r |                   |      |      |      |   |                     |
| e |                   |      |      |      |   |                     |
| [ |                   |      |      |      |   |                     |
| u |                   |      |      |      |   |                     |
| n |                   |      |      |      |   |                     |
| s |                   |      |      |      |   |                     |
| a |                   |      |      |      |   |                     |
| t |                   |      |      |      |   |                     |
| i |                   |      |      |      |   |                     |
| s |                   |      |      |      |   |                     |
| f |                   |      |      |      |   |                     |
| a |                   |      |      |      |   |                     |
| c |                   |      |      |      |   |                     |
| t |                   |      |      |      |   |                     |
| o |                   |      |      |      |   |                     |
| r |                   |      |      |      |   |                     |
| y |                   |      |      |      |   |                     |
| ] |                   |      |      |      |   |                     |
| { |                   |      |      |      |   |                     |
| . |                   |      |      |      |   |                     |
| u |                   |      |      |      |   |                     |
| n |                   |      |      |      |   |                     |
| d |                   |      |      |      |   |                     |
| e |                   |      |      |      |   |                     |
| r |                   |      |      |      |   |                     |
| l |                   |      |      |      |   |                     |
| i |                   |      |      |      |   |                     |
| n |                   |      |      |      |   |                     |
| e |                   |      |      |      |   |                     |
| } |                   |      |      |      |   |                     |
| a |                   |      |      |      |   |                     |
| n |                   |      |      |      |   |                     |
| d |                   |      |      |      |   |                     |
| t |                   |      |      |      |   |                     |
| h |                   |      |      |      |   |                     |
| e |                   |      |      |      |   |                     |
| a |                   |      |      |      |   |                     |
| p |                   |      |      |      |   |                     |
| p |                   |      |      |      |   |                     |
| l |                   |      |      |      |   |                     |
| i |                   |      |      |      |   |                     |
| c |                   |      |      |      |   |                     |
| a |                   |      |      |      |   |                     |
| n |                   |      |      |      |   |                     |
| t |                   |      |      |      |   |                     |
| h |                   |      |      |      |   |                     |
| a |                   |      |      |      |   |                     |
| s |                   |      |      |      |   |                     |
| b |                   |      |      |      |   |                     |
| e |                   |      |      |      |   |                     |
| e |                   |      |      |      |   |                     |
| n |                   |      |      |      |   |                     |
| n |                   |      |      |      |   |                     |
| o |                   |      |      |      |   |                     |
| t |                   |      |      |      |   |                     |
| i |                   |      |      |      |   |                     |
| f |                   |      |      |      |   |                     |
| i |                   |      |      |      |   |                     |
| e |                   |      |      |      |   |                     |
| d |                   |      |      |      |   |                     |
| . |                   |      |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+
|   |                   | / /  |      |      |   |                     |
+---+-------------------+------+------+------+---+---------------------+

  -------------------------------------------------------------- ----------------- -------------------------------------------------------------- ------------ --------------------------------------------------------------
  **EVALUATORS PERFORMANCE REPORT (FAA USE ONLY)**                                                                                                             

  FTD                                                            Satisfactory                                                                     Date:        
                                                                 Unsatisfactory                                                                   (mm/dd/yy) / 
                                                                 Incomplete                                                                       /            

  Simulator                                                      Satisfactory                                                                     Date:        
                                                                 Unsatisfactory                                                                   (mm/dd/yy) / 
                                                                 Incomplete                                                                       /            

  Aircraft                                                       Satisfactory                                                                     Date:        
                                                                 Unsatisfactory                                                                   (mm/dd/yy) / 
                                                                 Incomplete                                                                       /            

  COMMENTS:                                                                                                                                                    

                                                                                                                                                               

                                                                                                                                                               

                                                                                                                                                               

                                                                                                                                                               

                                                                                                                                                               

                                                                                                                                                               

                                                                                                                                                               

                                                                                                                                                               

  FAA Inspector Name: (Print)                                                      Signature:                                                                  District Office:

                                                                                                                                                               

  **\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**                     **\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**                **\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
  -------------------------------------------------------------- ----------------- -------------------------------------------------------------- ------------ --------------------------------------------------------------