Dear ______________________,

I have determined, based upon the information on your application for medical certification and my medical examination, that you do not meet the medical standards established by the Federal Aviation Administration (FAA).  Your history of ______________ is (are) disqualifying under Title 14 of the Code of Federal Regulations (14 CFR), part 67, Medical Standards and Certification.

Therefore, based upon the authority delegated to me by the Administrator of the FAA, your application for medical certification is denied.  This denial is not a final agency action under Title 49 of the United States Code section 44703 and is subject to reconsideration by FAA’s Federal Air Surgeon (14 CFR 67.409). 

You are cautioned to abide by 14 CFR 61.53 relating to the prohibition on operations during medical deficiency.

TO REQUEST RECONSIDERATION OF MY DETERMINATION:

The request for reconsideration must be made in writing, within 30 days of the date of the denial and mailed to the following address:

            Manager, Aerospace Medical Certification Division, AAM-300
            Mike Monroney Aeronautical Center
            Federal Aviation Administration
            P.O. Box 26080
            Oklahoma City, Oklahoma  73125

WHAT HAPPENS IF I DO NOT ASK FOR RECONSIDERATION?

The FAA considers a failure to request reconsideration of the denial as your withdrawal of the application for medical certification from further consideration.

Sincerely,

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