+-----------------+-------+--------------------------------------------+
| FORM APPROVED   |       |                                            |
| O.M.B. No.      |       |                                            |
| 004-R-0176      |       |                                            |
+-----------------+-------+--------------------------------------------+
| U.S. DEPARTMENT |       | This report is authorized by law (49       |
| OF              |       | U.S.C. 1421) while you are not required\   |
| TRANSPORTATION  |       | to respond, your cooperation is needed to  |
|                 |       | make the results of this survey\           |
| FEDERAL         |       | comprehensive, accurate and timely.        |
| AVIATION        |       |                                            |
| ADMINISTRATION  |       |                                            |
|                 |       |                                            |
| **SAFETY        |       |                                            |
| IMPROVEMENT     |       |                                            |
| REPORT**        |       |                                            |
+-----------------+-------+--------------------------------------------+
| **PURPOSE:** To |       |                                            |
| invite your     |       |                                            |
| participation   |       |                                            |
| in The General  |       |                                            |
| Aviation        |       |                                            |
| Accident        |       |                                            |
| Prevention      |       |                                            |
| Program. This   |       |                                            |
| form is         |       |                                            |
| provided for    |       |                                            |
| you to offer\   |       |                                            |
| ideas for       |       |                                            |
| program         |       |                                            |
| improvement or  |       |                                            |
| to report       |       |                                            |
| hazards on or   |       |                                            |
| adjacent to     |       |                                            |
| airport traffic |       |                                            |
| patterns;       |       |                                            |
| incomplete,     |       |                                            |
| inaccurate or   |       |                                            |
| obsolete flight |       |                                            |
| data\           |       |                                            |
| (charts or      |       |                                            |
| publications);  |       |                                            |
| malfunctioning  |       |                                            |
| navigation      |       |                                            |
| aids;           |       |                                            |
| contaminated    |       |                                            |
| fuel; etc. This |       |                                            |
| report is not   |       |                                            |
| intended to be  |       |                                            |
| used to\        |       |                                            |
| report          |       |                                            |
| violations of   |       |                                            |
| Federal         |       |                                            |
| Aviation        |       |                                            |
| Regulations.    |       |                                            |
+-----------------+-------+--------------------------------------------+
| USE THE SPACE   |       |                                            |
| BELOW TO TELL   |       |                                            |
| US ABOUT YOUR   |       |                                            |
| PROGRAM IDEAS   |       |                                            |
| OR ABOUT A      |       |                                            |
| HAZARD THAT     |       |                                            |
| MIGHT CAUSE AN  |       |                                            |
| ACCIDENT.\      |       |                                            |
| (*If you are    |       |                                            |
| reporting a     |       |                                            |
| hazard, tell us |       |                                            |
| what it is,     |       |                                            |
| where it is     |       |                                            |
| located, and    |       |                                            |
| when it was     |       |                                            |
| noticed.)*      |       |                                            |
+-----------------+-------+--------------------------------------------+
| DATE            | YOUR  |                                            |
|                 | NAME  |                                            |
|                 | AND   |                                            |
|                 | AD    |                                            |
|                 | DRESS |                                            |
|                 | *(    |                                            |
|                 | Optio |                                            |
|                 | nal)* |                                            |
+-----------------+-------+--------------------------------------------+
| **FAA FORM      |       |                                            |
| 8740-5** (3-80) |       |                                            |
| FORMERLY FAA    |       |                                            |
| FORM 8000-7     |       |                                            |
| (2-71)          |       |                                            |
+-----------------+-------+--------------------------------------------+