Free Application for Certificate, Production Certificate, or Supplemental Type Certificate - Federal

INFORMATION FOR APPLICANT
U.S. Department of Transportation

Federal Aviation Administration

APPLICATION FOR TYPE CERTIFICATE, PRODUCTION CERTIFICATE, OR SUPPLEMENTAL TYPE CERTIFICATE
Paperwork Reduction Act Statement: This collection of information is for the purpose of issuing a U.S.Type Certificate, Production Certificate, or Supplemental Type Certificate to any applicant meeting the criteria established in 14 CFR part 21. The FAA uses the information to evaluate an applicant's application for a U.S. Type Certificate, Production Certificate, or Supplemental Type Certificate. The information on FAA Form 8110-12, Application for Type Certificate, Production Certificate, or Supplemental Type Certificate is solicited under the authority of 49 U.S.C. 44702 as implemented by 14 CFR part 21. The burden associated with completing FAA Form 8110-12 is 48 minutes. Providing this information is mandatory if an applicant wishes to obtain a Type Certificate, Production Certificate, or Supplemental Type Certificate. Confidentiality is neither provided nor necessary. 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 of information is 2120-0018. Comments concerning the 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 this cover sheet before submitting this form.

FAA Form 8110-12 (4-03) Supersedes Previous Edition

No certificate may be issued unless a completed application form has been received (14 C.F.R.-21) U.S. DEPARTMENT OF TRANSPORTATION FEDERAL AVIATION ADMINISTRATION

APPLICATION FOR TYPE CERTIFICATE, PRODUCTION
CERTIFICATE, OR SUPPLEMENTAL TYPE CERTIFICATE

1. Name and address of applicant: 2. Application made for:
Type Certificate Production Certificate

FORM APPROVED O.M.B. No. 2120-0018 09/30/2007

3. Product Involved :
Aircraft Engine Propeller

Supplemental Type Certificate 4. TYPE CERTIFICATE (Complete item 4a below)

a. Model designation (s) (All models listed are to be completely described in the required technical data, including drawings representing the design, material, specifications, construction, and performance of the aircraft, aircraft engine, propeller which is the subject of this application.)

5. PRODUCTION CERTIFICATE: (Complete items 5a-c below. Submit with this form, in manual form, one copy of quality control data or changes thereto coveting new products, as required by applicable FAR.) a. Factory address: (if different from above) b. Application is for:
New production certificate Additions to production Certificate (Give P.C. No.) P.C. No.

c. Applicant is holder of or a licensee under a Type Certificate or a Supplemental Type Certificate:
(Attach evidence of licensing agreement and give certificate number)

T.C./S.T.C. No.

6. SUPPLEMENTAL TYPE CERTIFICATE: (Complete items 6a-d below) a. Make and model designation of product to be modified:

b. Description of modification:

c. Will data be available for sale or release to other persons ? Yes No

d. Will parts be manufactured for sale? (Ref. FAR 21.303) Yes No

7. CERTIFICATION - I certify that the above statements are true. Signature of Certifying Official Title Date

FAA Form 8110-12 (4-03) Supersedes Previous Edition