Free Application for Certificate - Federal

Form Approved OMB No. 2120-0675 03/31/2008

APPLICATION FOR CERTIFICATE

FAA USE ONLY Site Number

Department of Transportation Airport Operating Certificate Time-Limited Airport Operating Certificate Federal Aviation Administration Complete all sections of the form as indicated. Submit original and three copies of the form and two copies of the Airport Certification Manual to the headquarters of the appropriate FAA Regional Office. Type of Submission (Check One)
Original A. Location of Airport 1. Name of Airport 3. City 6a. Latitude ° B. Ownership 1. Municipality Corporation Port Authority 3. Name of Owner Number/Street/P.O. Box City County State Zip State County Military Other (Explain) 2. Airport is Civil Mil/Civ Joint Use Shared Use 4. Name of Manager/Operator Number/Street/P.O. Box City County State Zip ' " 6b. Longitude ° ' " 2. Address (Number, Street, P.O. Box) 4. County Airport is: a. State Licensed b. State Inspected 5. State 6. Zip Code Amendment Exemption

Yes Yes

No No

Airport Authority

C. Operative Data 1. Certificate Applied For: Class I Class II Class III Class IV 2. Fire Fighting Equipment (Check Current Index and ensure equipment is listed in ACM) A 3. Air Carriers to be served (UA, DL, CO, AA, etc.) 5. ARFF Exemption Applied For: Yes D. Remarks No Check here and use additional sheet of paper. B C D E 4. Air Carrier Aircraft to be served (737, DC-9, A-320, etc.) 6. Other exemptions applied for:

E. Certification This application, including the Airport Certification Manual, is submitted in order to obtain an Airport Operating Certificate or Time-Limited Airport Operating Certificate. I certify, under penalty of 18 U.S. Code, Section 1001, and other applicable provisions of law that the statements and information in the application form and manual are complete and true to the best of my knowledge. Applicant Signature Applicant Address/Number/Street/P.O. Box Applicant Name (typed) Applicant Title Date Submitted City State Zip Telephone No. ( FAA Use Only 1. Date Application received 3. Date Inspection Completed 4. Recommended for Certificate Disapproval 5. Remarks Modification Letter of Authorization Date 2. Date Proposed for Inspection Signature Signature Title Title )

FAA 5280-1 (2-04) Supersedes Previous Edition
Paperwork Reduction Act Statement: The information collected on this form is necessary to determine applicant eligibility for airport operating certificates. The FAA estimates that it will take 200 hours to complete this form and develop an Airport Certification Manual or Airport Certification Specifications that must accompany this form. This collection of information is mandatory under 14 CFR Part 139. 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 control number for this collection of information is 2120-0675. 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