-------------------- ------------- --------- ---------------------------
  [FAA USE                                     
  ONLY]{.underline}                            

  DESIGNATOR CODE                    POI       

  VALIDATION DATE                    PMI       

  CERTIFICATE STATUS                 PAI       

                                               
  -------------------- ------------- --------- ---------------------------

  --------------- -------------------------------------------------------
  OPERATOR NAME   

  --------------- -------------------------------------------------------

  ------------- ----------------- ------ -- ----- ---------- -----------------------------
  Previous                                        If "YES"   
  Certificate                                     please     
  Information                                     complete   
                                                  lines 1-3  

  1             PREVIOUS                                     
                DESIGNATOR                                   

  2             PREVIOUS                                     
                CERTIFICATE \#                               

  3             PREVIOUS                                     
                CERTIFICATE                                  
                STATUS                                       
  ------------- ----------------- ------ -- ----- ---------- -----------------------------

  ---------------------------------------------------- ------------------
  OPERATING Federal Aviation Regulation (FAR)          Part121

  ---------------------------------------------------- ------------------

  ------------- ------------ ------- -- ------------ ------- -- -------------- -------
  REQUESTS -    Exemptions              Deviations              Reliability    
                                                                Program        

  ------------- ------------ ------- -- ------------ ------- -- -------------- -------

TYPE OF OPERATIONS (CHECK ALL APPROPRIATE BLOCKS See 14 CFR 119.3)

  ----- ------------------------ ----- ---------- ----------------------------
        Flag Carrier                   Domestic   
                                       Carrier    

        Supplemental Carrier                      
        PAX/CARGO (ODA)                           

        Supplemental Carrier                      
        CARGO ONLY (ODC)                          
  ----- ------------------------ ----- ---------- ----------------------------

Specify the number of employees in each of the following categories.

  ------------------------- ---------- ------------------------- ----------
  Type of Employee          Number     Type of Employee          Number

  PIC CAPTAINS                         OTHER PILOTS              

  CHECK AIRMAN                         FLIGHT ATTENDANTS         

  INSPECTORS                           DESIGNATED INSPECTORS     

  CERTIFICATED MECHANICS               NON CERT. MECHANICS       

  REPAIRMEN                            GROUND PERSONNEL          

  FLIGHT ENGINEERS                     DISPATCHERS               
  ------------------------- ---------- ------------------------- ----------

+--------------------------------+-------------------------------------+
| CREWMEMBER TRAINING            | AIRWORTHINESS AGREEMENTS            |
|                                |                                     |
| (CIRCLE ONE)                   | (CIRCLE ONE)                        |
+--------------------------------+-------------------------------------+
| A = CONTRACTS OUT MOST/ALL TNG | #######                             |
|                                | # A = CONTRACTS OUT MOST/ALL MAINT  |
+--------------------------------+-------------------------------------+
| P = CONTRACTS OUT MODERATE     | P = CONTRACTS OUT MODERATE AMOUNT   |
| AMOUNT                         |                                     |
+--------------------------------+-------------------------------------+
| N = NO TRAINING REQUIRED       | M = PERFORMS MOST/ALL MAINT         |
+--------------------------------+-------------------------------------+
| T = PERFORMS MOST/ALL TRAINING | N = NO AGREEMENTS REQUIRED          |
+--------------------------------+-------------------------------------+

[COMPANY PERSONNEL]{.underline}

(CEO) Chief Executive Officer

  ---------- -- ---------- ------ -------- ---- -- ------- -------- ----- ------ ------- -------- -- -------------
  NAME:                                                    TITLE:                                    

  ADDRESS:                                                                       CITY:               

  COUNTY:                         STATE:                                         ZIP:                

  PHONE:                   EXT:                    Cell:                                 Email:      
  ---------- -- ---------- ------ -------- ---- -- ------- -------- ----- ------ ------- -------- -- -------------

**AGENT FOR SERVICE (ASV) (LEGAL REPRESENTATIVE)**

  ---------- -- ---------- ------ -------- ---- -- ------- -------- ----- ------ ------- -------- -- -------------
  NAME:                                                    TITLE:                                    

  ADDRESS:                                                                       CITY:               

  COUNTY:                         STATE:                                         ZIP:                

  PHONE:                   EXT:                    Cell:                                 Email:      
  ---------- -- ---------- ------ -------- ---- -- ------- -------- ----- ------ ------- -------- -- -------------

(MGR) MANAGER

  -------- --------- ------ ------ ------- -------- ----- ------- -------- -------------
  NAME:                                    TITLE:                          

  PHONE:             EXT:          Cell:                          Email:   
  -------- --------- ------ ------ ------- -------- ----- ------- -------- -------------

**(DO) DIRECTOR OF OPERATIONS:**

  -------- --------- ------ ------ ------- -------- ----- ------- -------- -------------
  NAME:                                    TITLE:                          

  PHONE:             EXT:          Cell:                          Email:   
  -------- --------- ------ ------ ------- -------- ----- ------- -------- -------------

**(DOM) DIRECTOR OF MAINTENANCE:**

  -------- --------- ------ ------ ------- -------- ----- ------- -------- -------------
  NAME:                                    TITLE:                          

  PHONE:             EXT:          Cell:                          Email:   
  -------- --------- ------ ------ ------- -------- ----- ------- -------- -------------

**(CP) CHIEF PILOT:**

  -------- --------- ------ ------ ------- -------- ----- ------- -------- -------------
  NAME:                                    TITLE:                          

  PHONE:             EXT:          Cell:                          Email:   
  -------- --------- ------ ------ ------- -------- ----- ------- -------- -------------

**(CI) CHIEF INSPECTOR:**

  -------- --------- ------ ------ ------- -------- ----- ------- -------- -------------
  NAME:                                    TITLE:                          

  PHONE:             EXT:          Cell:                          Email:   
  -------- --------- ------ ------ ------- -------- ----- ------- -------- -------------

**(DOS) DIRECTOR OF SAFETY:**

  -------- --------- ------ ------ ------- -------- ----- ------- -------- -------------
  NAME:                                    TITLE:                          

  PHONE:             EXT:          Cell:                          Email:   
  -------- --------- ------ ------ ------- -------- ----- ------- -------- -------------

AREAS OF SCHEDULED OPERATIONS (CIRCLE REQUESTED AREAS)

AL=ALASKA CE=CENTRAL EA=EASTERN GL=GREAT LAKES

NE=NEW ENGLAND NM=NORTHWEST MOUNTAIN SO=SOUTHERN

SW=SOUTHWEST WP=WESTERN PACIFIC EU=EUROPE

  ---------------------------------------------- ------------ ------------
  WILL YOU CARRY DANGEROUS GOODS:                             

  ---------------------------------------------- ------------ ------------

[COMPANY LOCATIONS]{.underline}

(PBO) ADDRESS OF THE PRINCIPLE BASE OF OPERATIONS

  ---------- -- ---------- ------ -------- ---- -- ------ ----------- ------- ---- ---------------
  ADDRESS:                                                            CITY:        

  COUNTY:                         STATE:                              ZIP:         

  PHONE:                   EXT:                    FAX:                            
  ---------- -- ---------- ------ -------- ---- -- ------ ----------- ------- ---- ---------------

(MOL) MAIN OPERATIONS LOCATION

  ---------- -- ---------- ------ -------- ---- -- ------ ----------- ------- ---- ---------------
  ADDRESS:                                                            CITY:        

  COUNTY:                         STATE:                              ZIP:         

  PHONE:                   EXT:                    FAX:                            
  ---------- -- ---------- ------ -------- ---- -- ------ ----------- ------- ---- ---------------

\(MML\) MAIN MAINTENANCE LOCATION

  ---------- -- ---------- ------ -------- ---- -- ------ ----------- ------- ---- ---------------
  ADDRESS:                                                            CITY:        

  COUNTY:                         STATE:                              ZIP:         

  PHONE:                   EXT:                    FAX:                            
  ---------- -- ---------- ------ -------- ---- -- ------ ----------- ------- ---- ---------------

(PPT) PRIMARY PILOT TRAINING LOCATION

  ---------- -- ---------- ------ -------- ---- -- ------ ----------- ------- ---- ---------------
  ADDRESS:                                                            CITY:        

  COUNTY:                         STATE:                              ZIP:         

  PHONE:                   EXT:                    FAX:                            
  ---------- -- ---------- ------ -------- ---- -- ------ ----------- ------- ---- ---------------

[DOING BUSINESS AS:]{.underline}

List any fictitious business names registered with a State or with the
Department of Transportation.

  ----------------------------- -----------------------------------------
  PRIMARY DBA:                  

  OTHER DBA:                    

  WAIVERS REQUESTED (LIST       
  FARS):                        
  ----------------------------- -----------------------------------------

AIRCRAFT USED UNDER FAR 121

+-----------------------------------------------------------------------+
| > FOR COLUMNS \"TURB, VFR ONLY, DAY ONLY, COMMUTER\" ENTER A \"Y\" IF |
| > THE PARTICULAR MAKE AIRCRAFT FALLS INTO THAT CATEGORY.              |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
| > FOR \"#PAX, FLIGHT ATTENDANT, AND \# OF AIRCRAFT\" ENTER THE NUMBER |
| > REQUIRED OR THE NUMBER TO BE USED BY YOUR OPERATION.                |
+-----------------------------------------------------------------------+

+-----------------+------+-----+-----+-------+-----------+----------+
| ######### MA    | C    | VFR | TU  | #PAX  | FLT ATTEN | \# OF    |
| KE/MODEL/SERIES | LASS |     | RB. |       |           | ACFT     |
+-----------------+------+-----+-----+-------+-----------+----------+
|                 |      |     |     |       |           |          |
+-----------------+------+-----+-----+-------+-----------+----------+
|                 |      |     |     |       |           |          |
+-----------------+------+-----+-----+-------+-----------+----------+
|                 |      |     |     |       |           |          |
+-----------------+------+-----+-----+-------+-----------+----------+
|                 |      |     |     |       |           |          |
+-----------------+------+-----+-----+-------+-----------+----------+

ENVIRONMENTAL DATA

  ------------------- ------------- --------------------------------------
  AIRPORT ID:                       (for Principal Base of Operations)

  ------------------- ------------- --------------------------------------

MAINTENANCE FACILITY ACTIVITIES: In the location column enter the
following abbreviations identifying where the maintenance function will
be performed.

> MMB= Main Maintenance Base
>
> MSB= Maintenance Sub-base
>
> MLS= Maintenance Line Station

  ----------------------- ---------- ---------------------- ---------------
  Maintenance Activity    Location   Maintenance Activity   Location

  FUELING                            NON-ROUTINE MAINT-A    

  CONTRACT MAINTENANCE               PERFORM B CHECKS       

  COMPANY MAINT PRSNT                MAJOR REPAIR/ALT -C    

  HANGAR FACILITY                    STRUCTURE REPAIR -D    

  PARTS                              INSP. - STRUCTURAL     

  MANUALS                            INSPECTIONS - NDT      

  AIRCRAFT RECORDS                   INSP - STR CORROS\'N   

  TRAINING RECORDS                   DEFERRED MAINT         

  SCHEDULED MAINT                    SAWRS                  

  UNSCHEDULED MAINT                                         
  ----------------------- ---------- ---------------------- ---------------

Operations Activities: In the location column enter the following
abbreviations identifying where the operations function will be
performed.

> OMB= Operations Main Base
>
> OSB= Operations Sub-base
>
> OLS= Operations Line Station

  ----------------------- ---------- ---------------------- ---------------
  Operations Activity     Location   Operations Activity    Location

  FLIGHT CREW BASE                   TRAINING DEVICES       

  DISPATCH                           FLIGHT LOCATING 121    

  TRIP RECORDS                       TRAINING FACILITY      

  CREWMEMBER RECORDS                 FLIGHT FOLLOWING       

  DISPATCHER RECORDS                                        

  SAWRS                                                     
  ----------------------- ---------- ---------------------- ---------------

[NUMBER OF TRAINING PROGRAMS:]{.underline}

  ------------- ---------- ----------- ---- -------- -- ------------ -------------
  DISPATCH:                PILOT                        PILOT        
                           GROUND:                      FLIGHT:      

  FLT ATTENDNT:            FLT                          NAVIGATOR:   
                           ENGINEER:                                 

  TOTAL NUMBER                                                       
  OF FLIGHTS                                                         
  per MONTH:                                                         

  AVERAGE                                                            
  NUMBER OF                                                          
  ARRIVALS PER                                                       
  MONTH                                                              
  ------------- ---------- ----------- ---- -------- -- ------------ -------------

Specify the number of employees in each of the following categories.

  ----------------------- --------- ---------------------- ---------------
  Type of Employee        Number    Type of Employee       Number

  PIC CAPTAINS                      OTHER PILOTS           

  CHECK AIRMAN                      FLIGHT ATTENDANTS      

  INSPECTORS                        DESIGNATED INSPECTORS  

  CERTIFICATED MECHANICS            NON CERT. MECHANICS    

  REPAIRMEN                         GROUND PERSONNEL       

  FLIGHT ENGINEERS                                         
  ----------------------- --------- ---------------------- ---------------

For each contractor listed below identify the type of services they
perform by placing a Y or N in each column.

> MX= Maintenance
>
> AX= Avionics Maintenance
>
> F= Fueling
>
> GH= Ground Handling
>
> MT= Maintenance Training
>
> AT= Avionics Training
>
> DI= De-Icing

  -------------------------------- ------ ---- ---- ---- ---- ----- ------
  Contractor Name                  MX     AX   F    GH   MT   AT    DI

                                                                    

                                                                    

                                                                    

                                                                    

                                                                    

                                                                    
  -------------------------------- ------ ---- ---- ---- ---- ----- ------

ENVIRONMENTAL MAKE-MODEL:

+--------+---------------+------------+-------------+----------------+
| A      | MAKE-MODEL    | M          | MAINTENANCE | STRUCTURAL     |
| irport |               | AINTENANCE | TRAINING    | INSP. PROGRAM  |
|        |               |            | (Y/N)       | (Y/N)          |
| ID     |               | (UM/SM/NM) |             |                |
+--------+---------------+------------+-------------+----------------+
|        |               |            |             |                |
+--------+---------------+------------+-------------+----------------+
|        |               |            |             |                |
+--------+---------------+------------+-------------+----------------+
|        |               |            |             |                |
+--------+---------------+------------+-------------+----------------+
|        |               |            |             |                |
+--------+---------------+------------+-------------+----------------+
|        |               |            |             |                |
+--------+---------------+------------+-------------+----------------+
|        |               |            |             |                |
+--------+---------------+------------+-------------+----------------+

NOTE 1: ENTER EACH TYPE OF AIRCRAFT THAT OPERATES AT THIS PARTICULAR
AIRPORT.

NOTE 2: FOR EACH MAKE-MODEL ENTERED, ENTER

UM - UNSCHEDULED MAINTENANCE

SM - SCHEDULED MAINTENANCE

NM - NO MAINTENANCE