Pilot Medical Application: History of Revoked Medical Certificate

Revoked, Suspended or Denied Certificates

Pilot Guide to FAA Medical Exam Items 13

Excerpts from Guide for Aviation Medical Examiners
Application Process for Medical Certification

Applicant History
Item 13. Has Your FAA Airman Medical Certificate Ever Been Denied, Suspended, or Revoked?

The applicant shall check yes or no. If yes is checked, the applicant should enter the date of action and should report details in the EXPLANATIONS box of Item 18.

The Examiner may not issue a medical certificate to an applicant who has checked yes. The only exceptions to this prohibition are:

The applicant presents written evidence from the FAA that he or she was subsequently medically certificated and that an Examiner is authorized to issue a renewal medical certificate to the person if medically qualified; or
The Examiner obtains oral or written authorization to issue a medical certificate from an FAA medical office

Other Portions of Applicant History:

Item(s)	Description
1-2	Application For: Class of Medical Certificate Applied For
3	Last Name; First Name; Middle Name
4	Social Security Number (SSN)
5	Address and Telephone Number
6	Date of Birth
7	Color of Hair
8	Color of Eyes
9	Sex
10	Type of Airman Certificate(s) You Hold
11-12	Occupation, Employer
13	Has Your FAA Airman Medical Certificate Ever Been Denied, Suspended, or Revoked?
14-15	Total Pilot Time
16	Date of Last FAA Medical Application
17 a	Do You Currently Use Any Medication (Prescription or Nonprescription)?
17 b	Do You Ever Use Near Vision Contact Lens(es) While Flying?
18	Medical History
19	Visits to Health Professional Within Last 3 Years
20	Applicant's National Driver Register and Certifying Declaration

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