APPLICATION FOR REPLACEMENT OF LOST OR DESTROYED
AIRMAN CERTIFICATE(S) AND KNOWLEDGE TEST REPORT(S)

PRIVACY ACT: This information is required under the authority of the Federal Aviation Act (Section 602). Certification cannot be completed unless the data is complete. Disclosure of your Social Security Number (SSN) is optional. Routine uses of records maintained in the system include categories of users and the purposes of such uses; i.e., to determine that airmen are certified in accordance with the provision of theFederal Aviation Act of 1958; repository of documents used by individual and potential employers to determine validity of airmen qualifications; to support investigative efforts of investigation and law enforcement agencies of Federal, State, and local governments; supportive infor-mation in court cases concerning individual status and/or qualifications in law suits; to provide data for the Comprehensive Airman Information System (CAIS); and to provide documents for microfilm and microfiche backup records.

             Type of Certificate(s)                          Certificate Numbers(s)                      Date(s) of Issuance

_____________________________   ________________________    ______________________
_____________________________   ________________________    ______________________
_____________________________   ________________________    ______________________

                     Type of Test                                  Location Test Was Taken            Date of Knowledge Test

_____________________________   ________________________     ______________________
_____________________________   ________________________     ______________________

Complete name in which certificate was issued:   ____________________________________________                                                                                         (first)                              (middle)                               (last)

Present mailing ___________________________   Physical address:   __________________________
address:                                                                                (If applicable)
                            ___________________________                                     __________________________

                            ___________________________                                      __________________________

(If address is a PO Box, Rural Route, General Delivery, or Star Route, please provide a physical address, directions or map for locating your residence.)

Date and place of birth: ___________________________    __________________________________
                                                                 (Date)                                                              (Place)

Physical Description: Height (Inches)_______ Weight (lbs.) ________ Hair ______ Eyes ______ Sex ___

Social Security Number: _______________________ Citizenship: ______________________________

I enclose     ____ check  _____ money order              in the amount of $ ______________ .

        ___________________                  ____________________________________
                        Date                                                                      Signature

The fee for each duplicate Airman or Medical Certificate is $2. The fee for each knowledge test report is $1. Check or money order for total fees (payable to the Federal Aviation Administration) must accompany request. 

For Airman Certificate or knowledge test      For Medical or combined Student/Medical,          For radio/telephone license
Report, mail this request to:                          mail this request to:                                             mail this request to:
   Federal Aviation Administration                   Federal Aviation Administration                         Federal Communication
   Airmen Certification Branch                         AFS-760 Cashier                                                 Commision    AFS-755
   Post Office Box 25082                                 Post Office Box 25082                                       1919 "M" Street NW    
   Oklahoma City, OK 73125-4940                  Oklahoma City, OK 73125-4939                        Washington, DC   20554

    AC Form 8060-56 (11/99) (NSN 0052-00-555-2004) Supersedes previous edition