Free Agricultural Aircraft Operator Certificate Application - Federal

US Department of Transportation Federal Aviation Administration

AGRICULTURAL AIRCRAFT OPERATOR CERTIFICATE APPLICATION
Paperwork Reduction Act Statement: The information collected on this form is required. This form is submitted to determine eligibility for the issuance of the Agriculture Aircraft Operator Certificate. Confidentiality is neither requested nor provided. We estimate that it will take 1 hour to complete the form. Please note that an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number associated with this collection is 2120-0049. Comments concerning the accuracy of this burden and suggestions for reducing the burden should be directed to the FAA at: 800 Independence Ave. SW, Washington, DC 20591
Attn: Information Collection Clearance Officer, ABA-20

TEAR OFF BEFORE USE
Form 8710-3 (10-83)

SUPPLEMENTAL INFORMATION
DETACH THIS PART BEFORE USING FORM BELOW

Form Approved OMB No. 2120-0049 05/31/2009

US Department of Transportation Federal Aviation
Administration


AGRICULTURAL AIRCRAFT OPERATOR CERTIFICATE APPLICATION

TYPE PRIVATE COMMERCIAL
FOR DISPENSING (Check one) ECONOMIC POISONS

INSTRUCTIONS Submit in duplicate to the local
General Aviation District Office.
ORIGINAL AMENDMENT
REISSUANCE

1. APPLICATION FOR


OTHER THAN ECONOMIC POISONS

2. NAME AND ADDRESS OF APPLICANT

3. PRINCIPAL OPERTIONS BASE (Airport, City, State)

TELEPHONE NUMBER

TELEPHONE NUMBER INDIVIDUAL CORPORATION PARTNERSHIP
OTHER (Specify) 5. NAME OF CHIEF SUPERVISOR OF OPERATIONS IF OTHER THAN SHOWN IN ITEM 2. (COMMERCIAL OPERATIONS ONLY) (First) (Middle Initial) CERTIFICATE NUMBER
RATINGS
ASEL AMEL ASES AMES HELICOPTER
GYROPLANE TYPE RATING(S) (Specify)
(Last)

2. OPERATING AS

6. AIRMAN CERTIFICATE HELD GRADE
PRIVATE
COMMERCIAL
AIRLINE TRANSPORT


7A.

DO YOU HOLD A CURRENTLY EFFECTIVE CERTIFICATE OF WAIVER FOR CONDUCTING AGRICULTURAL AIRCRAFT OPERATIONS?

DATE ISSUED EXPIRATION DATE

NO
YES (Complete 7B)
FAA DISTRICT OFFICE WHERE ISSUED

7B. WAIVER HELD

8. AGRICULTURAL AIRCRAFT TO BE OPERATED MAKE MODEL EQUIPPED FOR LIQUID SOLID TOTAL NUMBER EACH AIRCRAFT OPERATED REGISTRATION MARK (List one)

9. LIST THE NAME(S) AND AIRMAN CERTIFICATE NUMBER OF AGRICULTURAL PILOT(S) WORKING FOR YOU AT THE PRESENT TIME (Use separate sheet and attach if additional space is needed.)
NAME CERT. NO. NAME CERT. NO.

10. REMARKS

11. CERTIFICATION: I CERTIFY THAT STATEMENTS MADE ON THIS FORM ARE TRUE AND CORRECT.
DATE TITLE SIGNATURE

FAA Form 8710-3

(10-83)

INSPECTION REPORT - For FAA Use Only
(To be completed by the General Aviation for Flight Standards District Office) COMPLIANCE WITH APPLICABLE REGULATIONS 1. PILOTS A. CERTIFICATES B. RATING(S) C. KNOWLEDGE TEST D. SKILL TEST 2. AIRCRAFT A. CERTIFICATED B. AIRWORTHY C. EQUIPPED FOR AGRICULTURAL OPERATIONS
10. REMARKS (Include an explanation of denial if application is disapproved).

NOT REQUIRED

SATISFACTORY

UNSATISFACTORY

4. DISTRICT OFFICE ACTION CERTIFICATE ISSUED APPLICATION DISAPPROVED DATE INSPECTION COMPLETED INSPECTORS SIGNATURES