Free CERTIFICATE OF WAIVER OR AUTHORIZATION APPLICATION - Federal

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DEPARTMENT OF TRANSPORTATION
FEDERAL AVIATION ADMINISTRATION

SUPPLEMENTAL INFORMATION

CERTIFICATION OF WAIVER OR AUTHORIZATION APPLICATION - PRIVACY ACT The information on the accompanying form is solicited under authority of Federal Aviation Regulations Parts 91, 101, and 105. Submission of the information is mandatory. The purpose of this information is to establish eligibility for certificate of waiver or authorization The data will be used for recordkeeping and statistical purposes. Incomplete submission may result in delay or denial of your request. FAA Form 7711-2 (8-08) Supersedes Previous Edition
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No certificate may be issued unless a completed application form has been received (14 C.F.R. 91. 101. and 105).

From Approved: O.M.B. No.2120-0027 08/31/2008 US Department of Transportation Federal Aviation Administration
Region Action

APPLICANTS - DO NOT USE THESE SPACES
Date

APPLICATION FOR CERTIFICATE OF WAIVER OR AUTHORIZATION
Submit this application in triplicate (3) to any FAA Flight Standards district office. Applicants requesting a Certificate of Waiver or Authorization for an aviation event must complete all the applicable items on this form and attach a properly marked 7.5 series Topographic Quadrangle Map(s), published by the U.S. Geological Survey (scale 1:24,000), of the proposed operating area. The map(s) must include scale depictions of the flightlines, showlines, race courses, and the location of the air event control point, Police dispatch, ambulance, and fire
1. Name of organization

Approved

Disapproved ­ "Explain under "Remarks"

Signature of authorized FAA representative

INSTRUCTIONS
fighting equipment. The applicant may also wish to submit photographs and scale diagrams as supplemental material to assist in the FAA's evaluation of a particular site. Application for a Certificate of Waiver or Authorization must be submitted 45 days prior to the requested date of the event. Applicants requesting a Certificate of Waiver or Authorization for activities other than an aviation event will complete items 1 through 10 only and the certification, item 17, on the reverse.
2. Name of responsible person

3. Permanent mailing address

House number and street or route number

City

State and ZIP code

Telephone No.

4. State whether the applicant or any of its principal officers/owners has an application for waiver pending at any other office of the FAA.

5. State whether the applicant or any of its principal officers owners has ever had its application for waiver denied, or whether the FAA has ever withdrawn a waiver from the applicant or any of its
principal officers/owners.

6. FAR section and number to be waived .

7. Detailed description of proposed operation (Attach supplement if needed)

8. Area of operation (Location, altitudes, etc.)

9a. Beginning (Date and hour) 10. Aircraft make and model (a)

b. Ending (Date and hour) Certificate number and rating (c) Home address (Street, City, State) (d)

Pilot's Name (b)

FAA Form 7711 -2 (8-08) Supersedes Previous Edition

ITEMS 11 THROUGH 16 TO BE FILLED OUT FOR AIR SHOW/AIR RACE WAIVER REQUESTS ONLY. 11. The air event will be sponsored by:

12. Permanent mailing address

House number and street or route number

City

State and ZIP code

Telephone No.

13. Policing (Describe provisions to be made for policing the event.)

14. Emergency facilities (Mark all that will be available at time and place of air event.)

Physician Ambulance

Fire truck Crash wagon

Other - Specify

15. Air Traffic control (Describe method of controlling traffic, including provision for arrival and departure of scheduled aircraft.)

16. Schedule of Events (include arrival and departure of scheduled aircraft and other periods the airport maybe open.) Hour (a) Date (b) Event (c)

If sufficient space is not available, the entire schedule of events may be submitted on separate sheets, in the order and manner indicated above.

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The undersigned applicant accepts full responsibility for the strict observance of the terms of the Certificate of Waiver or Authorization, and understands that the authorization contained in such certificate will be strictly limited to the above described operation.

17. Certification - I CERTIFY that the foregoing statements are true.
Date Signature of Applicant

Remarks

FAA Form 7711-2 (8-08) Supersedes Previous Edition