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Name: Applicant History

FAA Pilot Medical Exam Item 2

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

Applicant History
Item 3. Last Name; First Name; Middle Name

The applicant's last, first, and middle name (or initial if appropriate) must be printed. All applicants without a middle name should enter NMN or NONE. Nicknames and abbreviated names must not be used.

Note: If the applicant's name changed for any reason, the current name is listed on the application and any former name(s) in the EXPLANATIONS box of Item 18 on the application. Continue with Demographic items...

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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