U.S. Department

of Transportation

Federal

Aviation

Administration

 Advisory

 Circular

Subject: APPLICATION FOR U.S. Date: 11/06/01 AC No: 21-12B

AIRWORTHINESS CERTIFICATE, Initiated by: AIR-210 Change:

FAA FORM 8130-6

___________________________________

1. PURPOSE. This advisory circular (AC) provides guidance and information on the preparation and

submittal of Federal Aviation Administration (FAA) Form 8130-6, Application for Airworthiness

Certificate. This application is completed to obtain an airworthiness certificate and for an amendment or

modification to a current airworthiness certificate. Form 8130-6 is not required for the issuance of a

replacement airworthiness certificate.

2. CANCELLATION. AC 21-12A, Application for U.S. Airworthiness Certificate, FAA Form 8130-6

(OMB 2120-0018), dated March 26, 1987, is cancelled.

3. PRINCIPAL CHANGES.

a. Instructions for completing Form 8130-6 have been updated and revised to reflect minor changes

to the new version of Form 8130-6, dated May 2001.

b. Appendix 1, Listing of FAA Regional Offices, has been removed and reference information for

contacting these offices has been added to the AC.

c. Title 14 Code of Federal Regulations (14 CFR) references have been revised and the text

reworded for clarification.

4. RELATED READING MATERIAL.

a. Title 14 Code of Federal Regulations:

(1) 14 CFR part 21, Certification Procedures for Products and Parts (part 21).

(2) 14 CFR part 39, Airworthiness Directives (part 39).

(3) 14 CFR part 43, Maintenance, Preventive Maintenance, Rebuilding, and Alteration (part 43).

(4) 14 CFR part 45, Identification and Registration Marking (part 45).
AC 21-12B 11/06/01

Page 2 Par 4

(5) 14 CFR part 47, Aircraft Registration (part 47).

(6) 14 CFR part 91, General Operating and Flight Rules (part 91).

b. FAA Order 8130.2, Airworthiness Certification of Aircraft and Related Products.

c. FAA Advisory Circulars:

(1) AC 20-27, Certification and Operation of Amateur-Built Aircraft.

(2) AC 20-65, U.S. Airworthiness Certificates and Authorization for Operation of Domestic and

Foreign Aircraft.

(3) AC 20-126, Aircraft Certification Service Field Office Listing.

(4) AC 21-4, Special Flight Permits for Operation of Overweight Aircraft.

(5) AC 21-37, Primary Category Aircraft.

(6) AC 39-7, Airworthiness Directives.

5. INFORMATION. The current version of Form 8130-6 (dated May 2001) may be obtained free of

charge at any Manufacturing Inspection District Office (MIDO) or Flight Standards District Office

(FSDO). Applicants may continue to use Form 8130-6 (dated November 1988) while the newer form is

distributed for availability. A geographic listing of the location, phone number, and FAX number of the

nearest MIDO can be found in AC 20-126, Aircraft Certification Service Field Office Listing. Similar

information for FSDO’s can be found by accessing the FAA website at: www.faa.gov.

6. INSTRUCTIONS FOR COMPLETING FORM 8130-6. The applicant, or the applicant’s agent,

should complete sections I through IV when submitting an application for an airworthiness certificate. If

submitting an application for a special flight permit, only sections II and VI, or II and VII, as applicable,

are required. The following instructions apply to the corresponding items on the form:

a. Section I. Aircraft Description.

NOTE: Do not complete this section when application is being submitted for a

special flight permit.

(1) Registration Mark. Enter the United States (U.S.) nationality designator letter “N”

followed by the registration marks as shown on the aircraft registration certificate. (Reference part 45,

subpart C.)

(2) Aircraft Builder’s Name (Make). Enter the name of the manufacturer or builder as it

appears on the aircraft identification (ID) plate. (Reference section 45.13(a)(1).)
11/06/01 AC 21-12B

Par 6 Page 3

(a) For amateur-built aircraft, the aircraft make is the name of the builder. When two or

more persons are involved, enter only the name of the individual that is listed first on the aircraft’s ID

plate.

(b) For aircraft built from spare and/or surplus parts, the aircraft make is that of the Type

Certificate (TC) holder (as it appears on the applicable aircraft listing, specification, or Type

Certificate Data Sheet (TCDS)) together with the name of the builder (for example, Bell-Jackson).

(c) For surplus military aircraft (not assembled from spare and/or surplus parts), the

builder’s name will be as listed on the TCDS.

(3) Aircraft Model Designation. Enter the model designation as shown on the aircraft ID plate.

Trade names should not be used. (Reference section 45.13(a)(2).)

(a) For amateur-built aircraft, the model may be any arbitrary designation selected by the

builder. For aircraft purchased as a kit, the model designation assigned by the kit manufacturer should

be used.

(b) For aircraft built from spare and/or surplus parts, the model designation will be the civil

model shown on the TCDS to which the applicant shows conformity.

(c) For surplus military aircraft having a civil model counterpart, enter the civil model

designation along with the military model designation in parentheses. If the TC was issued under

section 21.27, the military model designation becomes the civil model designation.

(d) For surplus military aircraft type certificated under the provisions of section 21.25(a)(2)

in the restricted category, only the military designation will be entered.

(4) Year of Manufacture. Enter the year of manufacture if shown on the aircraft ID plate or as

reflected in the aircraft’s records.

(a) For aircraft eligible for standard airworthiness certificates, the year of manufacture is the

date (entered by the manufacturer) the aircraft was completed and met the FAA-approved type design

data. Inspection records reflect the date of aircraft completion.

(b) For aircraft other than the above, the year of manufacture is the date entered by the

builder in the inspection records or logbook, establishing that the aircraft is airworthy and eligible for the

certificate requested.

(5) Aircraft Serial Number. Enter the serial number as shown on the aircraft ID plate.

(Reference section 45.13(a)(3).)
AC 21-12B 11/06/01

Page 4 Par 6

(a) For amateur-built aircraft fabricated and assembled from the builder’s own design, the

serial number may be any arbitrary number assigned by the builder. For any aircraft fabricated and

assembled from a kit or plans, the aircraft identification information provided by the kit manufacturer or

plans designer should be used.

(b) For aircraft built from spare and/or surplus parts, enter the serial number assigned by the

builder. That number should not be confused with the serial numbers assigned by an original

manufacturer who builds the same type aircraft under a production approval. It is suggested that a letter

prefix or suffix, such as the builder’s name or initials, be used with the serial number to provide positive

identification.

(c) For surplus military aircraft, enter the manufacturer’s civil serial number. The military

serial number should be placed in parentheses following the civil serial number. If no civil serial

number exists, enter the military serial number.

(6) Engine Builder’s Name (Make). The engine make is the name of the manufacturer as it

appears on the engine ID plate. Abbreviations may be used (for example, “P&W,” “G.E.,” etc.). When

engines are not installed, as in the case of a glider or balloon, enter “not applicable” or “N/A.”

(Reference section 45.13(a)(1).)

(7) Engine Model Designation. When engine(s) are installed, enter the complete designation as

shown on the engine ID plate (for example, “O-320-A1B,” “PT6A-20A,” “CFM-56-3C-1,” etc.).

(Reference section 45.13(a)(2).)

(8) Number of Engines. When applicable, enter the quantity of engines installed on the aircraft.

(9) Propeller Builder’s Name (Make). Enter the name of the manufacturer as shown on the

propeller identification marking. Enter “not applicable” or “N/A” if propellers are not installed.

(Reference section 45.13(a)(1).)

(10) Propeller Model Designation. When applicable, enter the model designation as shown on

the propeller identification marking. For amateur-built aircraft having a propeller not identified in

accordance with section 45.13(a)(1), enter the propeller diameter times (X) pitch in lieu of propeller

model designation. (Reference section 45.13(a)(2).)

(11) Aircraft is Import. This block should be checked only if the aircraft was manufactured

outside the U.S. and certified under the provisions of section 21.29, and the applicant is seeking

airworthiness certification under the provisions of section 21.183(c).

b. Section II. Certification Requested. The following paragraphs refer to the applicable 14 CFR

for standard and special airworthiness certificates used to aid in the completion of Form 8130-6 (see

Appendix 1, figures 1-17, for illustrated examples of a completed Form 8130-6).

(1) Item A. Standard Airworthiness Certificate. This certificate is issued to type certificated

aircraft in the normal, utility, acrobatic, transport, commuter, and manned free balloon categories; and
11/06/01 AC 21-12B

Par 6 Page 5

for special classes of aircraft. Special class aircraft include gliders, airships, and other

non-conventional aircraft. Special class application is indicated by marking the standard and other

blocks (section II (A) of the application), and entering the type, (for example, glider, very light aircraft,

airship, etc.) in the blank space directly above the category blocks. For aircraft type certificated prior to

the adoption of categories, enter in the open space above the category blocks, the basis for certification

as shown in that aircraft’s TCDS or specification sheet (for example, Category N/A - Certification basis

CAR 04 A (Civil Air Regulations part 4a)). Applicable regulations are as follows:

(a) Section 21.183(a), New aircraft manufactured under a production certificate.

(b) Section 21.183(b), New aircraft manufactured under a type certificate only.

(c) Section 21.183(c), Import aircraft.

(d) Section 21.183(d), Other aircraft.

(2) Item B. Special Airworthiness Certificate. This certificate is issued to aircraft not

meeting the requirements for a standard airworthiness certificate. Special airworthiness certificates are

identified as primary, limited, provisional, restricted, experimental, and special flight permit.

Applicable regulations are as follows:

(a) Primary Airworthiness Certificate.

1. Section 21.184(a), New primary category aircraft manufactured under a

production certificate.

2. Section 21.184(b), Imported aircraft.

3. Section 21.184(c), Aircraft having a current standard airworthiness certificate.

4. Section 21.184(d), Other aircraft.

(b) Limited Airworthiness Certificate. Section 21.189, Issue of airworthiness certificate

for limited category aircraft.

(c) Provisional Airworthiness Certificate.

1. Section 21.221, Class I provisional airworthiness certificates. (May be issued for all

categories.)

2. Section 21.223, Class II provisional airworthiness certificates. (Transport category

only.)

(d) Restricted Airworthiness Certificate.
AC 21-12B 11/06/01

Page 6 Par 6

1. Section 21.185(a), Aircraft manufactured under a production certificate or type

certificate only.

2. Section 21.185(b), Other aircraft (surplus U.S. military aircraft or one previously type

certificated in another category).

3. Section 21.185(c), Import aircraft (type certificated in the restricted category in

accordance with section 21.29).

(e) Experimental Certificate.

1. Section 21.191(a), Research and development.

2. Section 21.191(b), Showing compliance with regulations.

3. Section 21.191(c), Crew training.

4. Section 21.191(d), Exhibition.

5. Section 21.191(e), Air racing.

6. Section 21.191(f), Market surveys.

7. Section 21.191(g), Operating amateur-built aircraft.

8. Section 21.191(h), Operating kit-built aircraft (primary category aircraft assembled

by a person(s) without the supervision and quality control of the production certificate holder).

(f) Special Flight Permit.

1. Section 21.197(a)(1), Flying the aircraft to a base where repairs, alterations, or

maintenance are to be performed, or to a point of storage.

2. Section 21.197(a)(2), Delivering or exporting the aircraft.

3. Section 21.197(a)(3), Production flight testing new production aircraft.

4. Section 21.197(a)(4), Evacuating aircraft from areas of impending danger.

5. Section 21.197(a)(5), Conducting customer demonstration flights in new production

aircraft that have satisfactorily completed production flight tests.

6. Section 21.197(b), Operation of an aircraft at a weight in excess of its maximum

certificated takeoff weight.
11/06/01 AC 21-12B

Par 6 Page 7

(3) Item C. Multiple Airworthiness Certificates. These certificates are issued to an applicant

in the restricted category and one or more other categories except the primary category. Section 21.187

identifies the requirements an applicant must comply with before multiple airworthiness certificates are

issued.

c. Section III. Owner’s Certification. Do not complete this section when application is being

submitted for a special flight permit.

(1) Item A. Registered Owner.

(a) Enter the name and address exactly as shown on the aircraft registration certificate.

(Reference part 47.)

(b) If Dealer, Check Here. This block should be checked ONLY if the aircraft is registered

under an aircraft dealer’s aircraft registration certificate. (Reference part 47, subpart C.)

(2) Item B. Aircraft Certification Basis.

(a) Aircraft Specification or TCDS and/or Aircraft Listing Block. This item should be

completed when an application is submitted for a standard, primary, limited, provisional, restricted, or

multiple airworthiness certificates.

(b) When application is submitted for multiple airworthiness certificates, the certification

basis for each certificate should be entered.

(c) When a TCDS or specification for a new aircraft or model HAS BEEN APPROVED

BUT NOT PUBLISHED, enter the date of approval, TC or specification number, and the word

“preliminary.” This item is not applicable when submitting an application for an experimental

certificate, therefore, “N/A” should be entered.

(d) Airworthiness Directives. This block should be checked to indicate compliance with all

applicable Airworthiness Directives (AD). Enter the number of the last biweekly supplement to the

Summary of Airworthiness Directives available as of the date of application. (For example, Biweekly

Supplement 97-06 was published on March 24, 1997.)

NOTE: Each AD contains an applicability statement specifying the

product to which it applies. Some aircraft owners and operators

mistakenly assume that AD’s are not applicable to aircraft certificated in

certain categories such as experimental or restricted. AD’s, unless

specifically limited apply to the make and model set forth in the

applicability statement regardless of category. The type certificate and

airworthiness certification categories are used to identify the product

affected. (Reference AC 39-7.)
AC 21-12B 11/06/01

Page 8 Par 6

(e) Supplemental Type Certificate (STC). This block is applicable to all standard

airworthiness certification; and special airworthiness certification in the restricted, limited, provisional,

and primary categories, and should be completed at the time of application. The number of each

installed STC should be entered. If more space is required, an attachment may be used.

(Reference part 21, subpart E.)

(3) Item C. Aircraft Operation and Maintenance Records.

(a) Maintenance records shall comply with section 91.417. This block is applicable to all

aircraft and should be checked to indicate that the recordkeeping requirements of section 91.417 have

been met. For example, section 91.417(a)(2)(i), requires the total service time of the airframe, each

engine, propeller, and rotor. Compliance to section 91.417(a)(2)(ii), requires a maintenance record of

the current status of life-limited parts of each airframe, engine, propeller, rotor, and appliance. All

entries should be written in English and not with erasable materials such as lead/carbon pencils.

(b) Total Airframe Hours. The total service time of the aircraft, including production flight

test time, should be entered.

(c) Experimental Only. When submitting an application for renewal of an experimental

certificate, or when requesting a change back to a standard certificate, the hours flown since the previous

experimental certificate was issued or renewed should be entered. If the application is for an original

issuance of an experimental certificate, zero hours should be entered.

(4) Item D. Certification. If the signature is the owner’s agent, a notarized letter from the

registered owner authorizing the agent to act on the owner’s behalf is required.

NOTE: The term AIRWORTHY, as stated in FAA Order 8130.2, Airworthiness

Certification of Aircraft and Related Products, means (1) the aircraft conforms

to its type design and (2) the aircraft is in a condition for safe operation. In the

case of an application for an aircraft in the experimental category, only the

“AIRCRAFT IS IN A CONDITION FOR SAFE OPERATION” portion of the

definition would apply for the purpose of this application.

d. Section IV. Inspection Agency Verification. This section should be completed only if the

application is for a standard airworthiness certificate in accordance with section 21.183(d). This section

should be left blank for all other certification actions.

e. Section V. FAA Representative Certification. Applicants should not make any entries in this

section. This information will be entered by the FAA Inspector/Designee who inspects the aircraft and

issues the certificate.

f. Section VI. Production Flight Testing. This section should be completed ONLY BY A

MANUFACTURER applying for a special flight permit for the purpose of flight testing production

aircraft. (Reference section 21.197(a)(3).)
11/06/01 AC 21-12B

Par 6 Page 9

g. Section VII. Special Flight Permit Purposes other than Production Flight Test.

(1) Item A. Description of Aircraft. Entries in this section should be the same as the

corresponding data recorded on the aircraft’s registration certificate and, as applicable, on the aircraft’s

identification plate.

(2) Item B. Description of Flight. Enter the present location of the aircraft in the From box

and the aircraft’s intended destination in the To box.

(a) The Via block should contain the name of an airport or city at some intermediate flight

point to provide a general description of the route flown. For example, a flight from Kansas City,

Missouri to Dallas, Texas may be flown via Wichita, Kansas and Oklahoma City, Oklahoma.

(Reference section 21.199(a)(2).)

(b) The Duration entry should reflect the overall duration of the special flight permit.

Factors such as fueling stops, weather conditions, overnight stops, or any other reasonable condition

should be given consideration when establishing the duration. (Reference section 21.199(a)(2).)

(3) Item C. Crew Required to Operate the Aircraft and its Equipment. Self-explanatory.

(4) Item D. The Aircraft Does Not Meet the Applicable Airworthiness Requirements as

Follows. This entry should contain in detail the conditions, if any, in which the aircraft does not comply

with the applicable airworthiness requirements. (Reference section 21.199(a)(4).)

(5) Item E. The Following Restrictions are Considered Necessary for Safe Operation. This

entry should contain in detail any restrictions the applicant considers necessary for safe operation of the

aircraft (for example, reduced airspeed or operating weight, turbulence avoidance, crew limitations or

qualifications, etc.). After review of the application, the FAA may prescribe additional conditions and/or

limitations deemed necessary for safe operation. (Reference section 21.199(a)(5) and (6).)

(6) Item F. Certification. Self-explanatory.

h. Section VIII. Airworthiness Documentation. This section will be completed by the FAA

Inspector/Designee who inspects the aircraft and issues the airworthiness certificate, and is not required

when the applicant is submitting an application for a special flight permit.

7. INSTRUCTIONS FOR SUBMITTING THE COMPLETED FAA FORM 8130-6. When the

applicant has completed the applicable sections and has signed the Form 8130-6, it should be submitted

to the local MIDO or FSDO. The nearest MIDO or FSDO location can be determined by referencing the

information in paragraph 5 of this AC. Other material may be required by the regulations for the final

airworthiness certification. In the case of a manufacturer holding a FAA production approval, an

application may be submitted to an authorized Designated Airworthiness Representative or Designated

Manufacturing Inspection Representative.
AC 21-12B 11/06/01

Page 10 Par 8

8. HOW TO OBTAIN THE REFERENCED PUBLICATIONS.

a. The CFR and those ACs for which a fee is charged may be obtained from the Superintendent of

Documents, P.O. Box 371954, Pittsburgh, PA 15250-7954. A listing of the CFR and current prices is

located in AC 00-44, Status of Federal Aviation Regulations, and a listing of all ACs is located in

AC 00-2, Advisory Circular Checklist.

b. To be placed on the FAA’s mailing list for free ACs, contact: U.S. Department of Transportation,

Subsequent Distribution Office, SVC-121.23, Ardmore East Business Center, 3341Q 75th Avenue,

Landover, MD 20785.

c. The FAA website at: www.faa.gov.

/S/

Frank P. Paskiewicz

Manager, Production and

Airworthiness Division, AIR-200
11/06/01 AC 21-12B

Appendix 1

Page 1

APPENDIX 1. SAMPLES OF FORM 8130-6, APPLICATION FOR AIRWORTHINESS

CERTIFICATE

FIGURE 1. SAMPLE FAA FORM 8130-6, APPLICATION FOR A STANDARD

AIRWORTHINESS CERTIFICATE – VERY LIGHT AIRCRAFT PRODUCED UNDER

SECTION 21.183(a)

(FACE SIDE ONLY)

APPLICATION FOR

AIR W OR TH IN ESS

CERTIFICATE

II. CERTIFICATION REQUESTED

EXPER IM EN TAL ON LY (Enter hours flow n s ince la st cert ificate

C ER TIFIC ATED M EC H AN IC (Give C ER TIFIC ATED R EPAIR STATION (Give C ertificate

AIR C R AFT SPEC I FIC ATION O R TYPE C ER TIFIC ATE D ATA SH EET (Give N o. and AIR W OR TH IN ES S D IR EC TIVES (C heck if all ap plica ble A D 's c om pli ed w i th an d giv e the num b er of

the las t AD SU PPL EM EN T avai lable in t he bi w eekl y ser ies a s of the d ate o f app licat ion) 

96- 23

issued or re newed)

0

 N o.)

R evision N o.)

A2W I R ev-1

 14 C F R par t 121 C ER T IFIC A TE H O LD ER (Give

C ertificate N o.)

A. R EGISTE R ED OW N ER (A s show n on c ertifi cate o f airc raft r egistr ation)

V. FAA 

REPRESENTATIVE 

CERTIFICATION

I. AIRCRAFT

DESCRIPTION III. OWNER'S CERTIFICATION

IV. INSPECTION 

AGENCY 

VERIFICATION

A

B

X STAN D AR D AIR W OR TH IN ESS C ER TIFIC ATE (Ind icate cate gory)

SPEC IAL AIR W OR TH IN ESS C ER TIFIC ATE (C heck approp riate item s)

1. R EGISTR ATION M AR K

 N 18C E

APPLIC AT ION IS H ER EBY M A D E FOR : (C heck a pplicabl e item s)

2. AIR C R AFT BU ILD ER 'S N AM E (M ake)

 Lite -Fligh t C orp

3. AIR C R AFT M OD EL D E SIGN ATION FAA C OD IN G

 L F-1-A

4. YR . M FR .

 96

7. EN GIN E M OD EL D E SIGN ATION

 912

10. PR O PELLER M OD EL D ESIG N ATION

 Go od-1 IM POR T

11. AIR C R AFT IS (C heck if appl icable)

DATE D ISTR IC T OFFIC E D ESIGN EE'S SIG N ATU R E AN D N O. FAA IN SPEC TOR 'S SIGN ATU R E

 (C heck ALL appli cable bloc ks in item s A a nd B)

A. I fin d th at t he a ircr aft desc ribe d in Sec tion I o r VI I me ets requ irem ents for

X X

NAME

Lite F light C orp

ADDRESS

1801 Airpo rt R d

W ichi ta, KS 67 209

B. AIR C R A FT C E R TIFI C ATIO N BAS IS (C heck appli cable bloc ks an d com plete item s as indic ated)

X

C . AIR C R AFT OPER ATION A N D M AIN TEN AN C E R EC OR D S

C H EC K IF R EC OR D S IN

 C OM PLIAN C E W ITH 

14 C F R se ctio n 91 .417

TOTAL AIR FR AM E H OU R S

2.0 3

D ATE OF APPLI C ATION

11/2 5/ 98

D . C ER TIFIC ATION - I hereby certify that I am the regi ster ed o w ner (or his age nt) of t he a ircr aft desc ribe d ab ove, tha t th e ai rcra ft i s re gist ered w it h th e Fe dera l Av iati on A dmin istr atio n in acc orda nce w ith

Title 49 of th e U nit ed Sta tes C o de 441 01 et se q . and appli cabl e Fe dera l Av iati on R egul atio ns, and that the air craf t ha s be en i nspe cted and is airw orth y an d el igib le f or t he a irw o rthi ness cer tifi cate

requ ested.

A. TH E AIR C R AFT D ES C R IBED ABOVE H AS B EEN IN SPECTE D AND FOU N D AIR W OR TH Y BY : (C om plete this sectio n only if 14 C FR p art 21 .183( d) app lies).

N AM E AN D T ITLE (Prin t or type)

K.D . Go od, D irect or QA

SIGN ATU R E

DATE TITLE SIGN ATU R E

INSTRUCTIONS - Print or type. D o not w rite in s haded areas ; thes e are for F AA

us e only. Subm it original only to an authorized F AA R epres entativ e. If additional

s pac e is required, us e attac hm ent. F or s pec ial flight perm its com plete Sec tions

II, VI, and VII as applic able.

B. Insp ecti on f or a spe cial fli ght perm it u nder Sec tion VII

 wa s c ond ucted by:

6. EN GIN E BU ILD ER 'S N AM E (M ake)

 R otax

9. PR OP ELLER B U ILD ER ' S N AM E (M ake)

 W o od B uilt

5. AIR C R AFT SER IAL N O.

 LF 010

8. N U M BER OF EN GIN ES

 One

IF D EA LER , C H EC K H ER E

AIR C R AFT LISTI N G (Gi ve pag e numb er(s))

N /A

SU PPLEM EN TAL TYPE C ER TI FIC AT E (Li st nu mber of ea ch ST C inc orpor ated)

N /A

 AIR C R AFT M AN U FAC TU R ER ( Give name or firm) 

U .S. D epa rtm ent

of Tr ansp orta tion

Federal A viation

A dministration

C ertificate N o.)

OM B. N o. 212 0-0 018

NORM AL UTILITY ACROBATIC TRANSPORT COM M UTER BALLOON

FAA Form 8130-6 (5-01) Supersedes Previous Edition NSN: 0052-00-024-7006

C M U LTIPLE AIR W OR TH IN ESS C ER TIFIC ATE (C heck ABOVE " R estr icted Oper ation " and "Sta ndard " or "Lim i ted" as ap plica ble.)

SPEC IAL FLIGH T PER M IT (Indi cate 

oper ati on to be con duc ted , t hen

 com ple te S ecti on V I or VII as 

applica ble o n rev erse side)

LIM ITED

PR OVIS ION AL (Indicat e class)

R ESTR IC TED (Indi cate opera tion( s) to

 be c ond ucted)

AGR IC U LTU R E AN D PEST C ON TR OL

FOREST (W ildlife c onservation)

CLAS S I

C LAS S II

AER IAL

PATR O LLIN G

 AER IAL AD VER TISIN G

 W EATHER CONTROL

AM ATEU R BU ILT

C R EW TR AIN IN G

EXH IBITION

MARKET SURVEY

D ELIVER IN G OR EX POR TIN G

TO SH OW C OM PLIAN C E W ITH TH E C FR

C U STOM ER D EM ON STR ATION FLIGH TS

PR OD U C TION FL IGH T TESTIN G

FER R Y FLI GH T FOR R EPAIR S, A LTER ATION S, M AIN T EN AN C E, O R STOR AGE

EVAC U ATE FR OM AR EA OF IM PE N D IN G D AN GER

OPER ATION IN EX C ESS OF M AX IM U M C ER TIF IC ATED TAKE -OFF W EIGH T

RESEARCH AND D EVELOPM ENT

EXPER IM EN TAL (Indica te op erati on(s) AIR R AC IN G

 to b e c ond uct ed)

OTHER (Specify)

OPER ATIN G (Prim ary C ategory) KIT BU ILT AIR C R AFT 

PR IM AR Y

FAA IN SPEC TOR

14 C FR par t 65

FAA D E SIGN EE

14 CFR part 121 OR 135 14 C FR pa rt 145

TH E C ER TIFIC A TE R EQU ESTED

AM EN D M EN T OR M OD IFIC ATION OF C U R R EN T AIR W OR TH IN ESS C ER TIFIC ATE

C ER TIFIC ATE H OLD ER U N D ER

Very Lig ht Ai rcraft

1 X OTHER

4 1

3 6

4

2

5

3

4

 8

3

6

3

2

5

1

2

4

1

0

1

4

0

7

6

4

3

2

1

5

7

2

5

6

6

5

2
AC 21-12B 11/06/01

Appendix 1

Page 2

FIGURE 2. SAMPLE FAA FORM 8130-6, APPLICATION FOR A STANDARD

AIRWORTHINESS CERTIFICATE – AIRCRAFT PRODUCED IN THE

TRANSPORT CATEGORY

(FACE SIDE ONLY)

APPLICATION FOR

AIRW ORTHINESS

CERTIFICATE

II. CERTIFICATION REQUESTED

EXPERIMEN TAL ONLY (Enter hours flown s ince last certificate

CERTIFICATED MECHANIC (Give CERTIFICATED R EPAIR STATION (Give Certificate

AIRCRAFT SPECIFICATION O R TYPE CER TIFICATE D ATA SHEET (Give No. and AIRW ORTHINES S DIRECTIVES (Check if all applicable A D's c ompli ed wi th and giv e the number of

the l ast A D SUP PLEME NT av ailable in the biweekly s eries as of the date of applic ation) 

96- 23

issued or renewed)

N/A

 No.)

Revision No.)

A16W E

 14 CF R part 121 C ERTIFICATE H OLDER (Give

Certificate No.)

A. REGISTE RED OW NER (A s show n on c ertifi cate of airc raft r egistr ation)

V. FAA 

REPRESENTATIVE 

CERTIFICATION

I. AIRCRAFT

DESCRIPTION III. OWNER'S CERTIFICATION

IV. INSPECTION 

AGENCY 

VERIFICATION

A

B

X STANDARD AIRW ORTHINESS CERTIFICATE (Indicate category)

SPECIAL AIR W ORTHINESS CERTIFICATE (Check appropriate items)

1. REGISTR ATION MARK

 NI2345

APPLICAT ION IS H EREBY MA DE FOR: (Check applicabl e items)

2. AIRCRAFT BU ILDER'S NAME (Make)

 B OEING

3. AIRCRAFT MODEL DE SIGNATION FAA CODING

 737-200

4. YR. MFR.

1968

7. ENGINE MODEL DE SIGNATION

 JT8D-9

10. PRO PELLER MODEL DESIG NATION

 N/A IMPORT

11. AIRC RAFT IS (Check if appl icable)

DATE DISTRICT OFFICE DESIGNEE'S SIG NATURE AND NO. FAA INSPECTOR 'S SIGNATURE

 (Check ALL appli cable bloc ks in item s A and B)

A. I find that the aircr aft desc ribed in Sec tion I or VII meets requirements for

X X

NAME

Shorthaul A irli nes, Inc

ADDRESS

111 Airport W ay, St Louis , Mi ssouri 58010

B. AIRCRA FT CE RTIFICATIO N BAS IS (C heck appli cable bloc ks and complete items as indic ated)

X

C. AIRCRAFT OPERATION A ND MAINTENANCE RECORDS

CHECK IF RECORDS IN

 COMPLIANCE W ITH 

14 CF R section 91.417

TOTAL AIRFRAME HOURS

8:45 3

DATE OF APPLICATION

11/25/96

D. CERTIFICATION - I hereby certify that I am the regi ster ed owner (or his agent) of the aircr aft desc ribed above, that the ai rcraft i s registered with the Federal Av iati on A dministr ation in acc ordance with

Title 49 of the U nited States Code 44101 et seq. and appli cabl e Federal Av iati on R egul ations, and that the air craft has been i nspected and is airw orthy and el igible for the a irworthi ness cer tifi cate

requested.

A. THE AIRCRAFT DES CRIBED ABOVE HAS B EEN IN SPECTED AND FOUND AIRW OR THY BY : (Complete this section only if 14 CFR part 21 .183( d) applies).

NAME AND T ITLE (Print or type)

John Doe, V P O per ati ons

SIGNATURE

DATE TITLE SIGNATURE

INSTRUCTIONS - Print or type. Do not write in shaded areas; these are for FAA

use only. Subm it original only to an authorized FAA Representative. If additional

space is required, use attachm ent. For special flight perm its com plete Sections

II, VI, and VII as applicable.

B. Inspecti on for a special fli ght permit under Sec tion VII

 was c onducted by:

6. ENGINE BUILDER 'S NAME (Make)

 Pratt & W hi tney

9. PROP ELLER B UILDER' S NAME (Make)

 N/A

5. AIRCR AFT SER IAL NO.

 19714

8. NUMBER OF ENGINES

 2

IF DEALER, CHECK HERE

AIRCRAFT LISTING (Gi ve page number(s)) SUPPLEMENTAL TYPE CERTIFICAT E (Li st number of each ST C inc orpor ated)

AIRCRAFT MANUFA CTURER (Give name or firm) 

U.S. D epartment

of Tr ansportation

Federal Aviation

Administration

Certificate No.)

 O.M .B. No. 2120-00180

NORMAL UTILITY ACROBATIC X TRANSPORT COMMUTER BALLOON

FAA Form 8130-6 (5-01) Supersedes Previous Edition NSN: 0052-00-024-7006

C MULTIPLE AIR W ORTHINESS CERTIFICATE (Check ABOVE " Restr icted Oper ation" and "Standard" or "Limi ted" as applicable.)

SPECIAL FLIGHT PERMIT (Indi cate 

oper ati on to be conduc ted, then

 complete S ecti on V I or VII as 

applicable on rev erse side)

LIMITED

PROVIS IONAL (Indicate class)

RESTRICTED (Indi cate operation( s) to

 be c onducted)

AGRICULTURE AN D PEST CONTROL

FOREST (W ildlife c onservation)

CLAS S I

CLAS S II

AERIAL

PATRO LLING

 AERIAL ADVER TISING

 WEATHER CONTROL

AMATEUR BUILT

CREW TRAINING

EXHIBITION

MARKET SURVEY

DELIVERIN G OR EX PORTING

TO SHOW COMPLIAN CE W ITH THE CFR

CUSTOMER DEMONSTRATION FLIGHTS

PRODUCTION FLIGHT TESTING

FERRY FLIGHT FOR R EPAIRS, A LTERATION S, MAINT ENANCE, O R STORAGE

EVACUATE FROM AREA OF IMPE NDING DANGER

OPERATION IN EX CESS OF MAX IMUM CERTIF ICATED TAKE -OFF W EIGHT

RESEARCH AND DEVELOPMENT

EXPERIM ENTAL (Indicate operati on(s) AIR RACING to be c onducted)

OTHER (Specify)

OPERATING (Primary Category) KIT BUILT AIRCRAFT 

PRIMARY

FAA INSPECTOR

14 CFR par t 65

FAA DE SIGNEE

14 CFR part 121 OR 135 14 CFR part 145

THE CERTIFICA TE REQUESTED

AMENDMENT OR MODIFICATION OF CURRENT AIRW ORTHINESS CERTIFICATE

CERTIFICATE HOLDER UNDER

1 OTHER

4 1

3 6

4

2

5

3

4

 8

3

6

3

2

5

1

2

4

1

0

1

4

0

7

6

4

3

2

1

5

7

2

5

6

6

2

5
11/06/01 AC 21-12B

Appendix 1

Page 3

FIGURE 3. SAMPLE FAA FORM 8130-6, APPLICATION FOR A STANDARD

AIRWORTHINESS CERTIFICATE – IMPORT GLIDER

(FACE SIDE ONLY)

APPLICATION FOR

AIRWORTHINESS

CERTIFICATE

II. CERTIFICATION REQUESTED

EXPERIMEN TAL ONLY (Enter hours flown s ince last certificate

CERTIFICATED MECHANIC (Give CERTIFICATED R EPAIR STATION (Give Certificate

AIRCRAFT SPECIFICATION O R TYPE CER TIFICATE D ATA SHEET (Give No. and AIRWORTHINES S DIRECTIVES (Check if all applicable A D's c ompli ed wi th and giv e the number of

the l ast A D SUP PLEME NT av ailable in the biweekly s eries as of the date of applic ation) 

96- 23

issued or renewed)

N/A

 No.)

Revision No.)

G15EU

 14 CF R part 121 C ERTIFICATE H OLDER (Give

Certificate No.)

A. REGISTE RED OW NER (A s show n on c ertifi cate of airc raft r egistr ation)

V. FAA 

REPRESENTATIVE 

CERTIFICATION

I. AIRCRAFT

DESCRIPTION III. OWNER'S CERTIFICATION

IV. INSPECTION 

AGENCY 

VERIFICATION

A

B

X STANDARD AIRWORTHINESS CERTIFICATE (Indicate category)

SPECIAL AIR WORTHINESS CERTIFICATE (Check appropriate items)

1. REGISTR ATION MARK

 N53B

APPLICAT ION IS H EREBY MA DE FOR: (Check applicabl e items)

2. AIRCRAFT BU ILDER'S NAME (Make)

 Sc hlei cher

3. AIRCRAFT MODEL DE SIGNATION FAA CODING

 A S-K13

4. YR. MFR.

 1984

7. ENGINE MODEL DE SIGNATION

 N/A

10. PRO PELLER MODEL DESIG NATION

 N/A X IMPORT

11. AIRC RAFT IS (Check if appl icable)

DATE DISTRICT OFFICE DESIGNEE'S SIG NATURE AND NO. FAA INSPECTOR 'S SIGNATURE

 (Check ALL appli cable bloc ks in item s A and B)

A. I find that the aircr aft desc ribed in Sec tion I or VII meets requirements for

X X

NAME

Elmer E. J ones

ADDRESS 

1601 E . 6th Str eet

 San Diego, cali fornia 95472 

B. AIRCRA FT CE RTIFICATIO N BAS IS (C heck appli cable bloc ks and complete items as indic ated)

X

C. AIRCRAFT OPERATION A ND MAINTENANCE RECORDS

CHECK IF RECORDS IN

 COMPLIANCE WITH 

14 CF R section 91.417

TOTAL AIRFRAME HOURS

320 3

DATE OF APPLICATION

11/25/96

D. CERTIFICATION - I hereby certify that I am the regi ster ed owner (or his agent) of the aircr aft desc ribed above, that the ai rcraft i s registered with the Federal Av iati on A dministr ation in acc ordance with

Title 49 of the U nited States Code 44101 et seq. and appli cabl e Federal Av iati on R egul ations, and that the air craft has been i nspected and is airw orthy and el igible for the airworthi ness cer tifi cate

requested.

A. THE AIRCRAFT DES CRIBED ABOVE HAS B EEN IN SPECTED AND FOUND AIRWOR THY BY : (Complete this section only if 14 CFR part 21 .183( d) applies).

NAME AND T ITLE (Print or type)

Elmer E. Jones, Owner

SIGNATURE

DATE TITLE SIGNATURE

INSTRUCTIONS - Print or type. Do not write in shaded areas; these are for FAA

use only. Submit original only to an authorized FAA Representative. If additional

space is required, use attachment. For special flight permits complete Sections

II, VI, and VII as applicable.

B. Inspecti on for a special fli ght permit under Sec tion VII

 was c onducted by:

6. ENGINE BUILDER 'S NAME (Make)

 N/A

9. PROP ELLER B UILDER' S NAME (Make)

 N/A

5. AIRCR AFT SER IAL NO.

 101

8. NUMBER OF ENGINES

 N/A

IF DEALER, CHECK HERE

AIRCRAFT LISTING (Gi ve page number(s))

N/A

SUPPLEMENTAL TYPE CERTIFICAT E (Li st number of each ST C inc orpor ated)

N/A

 AIR CRAFT MANU FACTURER ( Give name or firm) 

U.S. D epartment

of Tr ansportation

Federal Aviation

Administration

Certificate No.)

O.M.B. No. 2120-0018

NORMAL UTILITY ACROBATIC TRANSPORT COMMUTER BALLOON

FAA Form 8130-6 (5-01) Supersedes Previous Edition NSN: 0052-00-024-7006 

C MULTIPLE AIR WORTHINESS CERTIFICATE (Check ABOVE " Restr icted Oper ation" and "Standard" or "Limi ted" as applicable.)

SPECIAL FLIGHT PERMIT (Indi cate 

oper ati on to be conduc ted, then

 complete S ecti on V I or VII as 

applicable on rev erse side)

LIMITED

PROVIS IONAL (Indicate class)

RESTRICTED (Indi cate operation( s) to

 be c onducted)

AGRICULTURE AN D PEST CONTROL

FOREST (Wildlife c onservation)

CLAS S I

CLAS S II

AERIAL

PATRO LLING

 AERIAL ADVER TISING

 WEATHER CONTROL

AMATEUR BUILT

CREW TRAINING

EXHIBITION

MARKET SURVEY

DELIVERIN G OR EX PORTING

TO SHOW COMPLIAN CE WITH THE CFR

CUSTOMER DEMONSTRATION FLIGHTS

PRODUCTION FLIGHT TESTING

FERRY FLIGHT FOR R EPAIRS, A LTERATION S, MAINT ENANCE, O R STORAGE

EVACUATE FROM AREA OF IMPE NDING DANGER

OPERATION IN EX CESS OF MAX IMUM CERTIF ICATED TAKE -OFF WEIGHT

RESEARCH AND DEVELOPMENT

EXPERIM ENTAL (Indicate operati on(s) AIR RACING

 to be c onducted)

OTHER (Specify)

OPERATING (Primary Category) KIT BUILT AIRCRAFT 

PRIMARY

FAA INSPECTOR

14 CFR par t 65

FAA DE SIGNEE

14 CFR part 121 OR 135 14 CFR part 145

THE CERTIFICA TE REQUESTED

AMENDMENT OR MODIFICATION OF CURRENT AIRWORTHINESS CERTIFICATE

CERTIFICATE HOLDER UNDER

Import Gl ider

1 X OTHER

4 1

3 6

4

2

5

3

4

 8

3

6

3

2

5

1

2

4

1

0

1

4

0

7

6

4

3

2

1

5

7

2

5

6

6

5

2
AC 21-12B 11/06/01

Appendix 1

Page 4

FIGURE 4. SAMPLE FAA FORM 8130-6, APPLICATION FOR A STANDARD

AIRWORTHINESS CERTIFICATE – SURPLUS MILITARY AIRCRAFT

(FACE SIDE ONLY)

APPLICATION FOR

AIRW ORTHINESS

CERTIFICATE

II. CERTIFICATION REQUESTED

EXPERIMEN TAL ONLY (Enter hours flown s ince last certificate

CERTIFICATED MECHANIC (Give CERTIFICATED R EPAIR STATION (Give Certificate

AIRCRAFT SPECIFICATION O R TYPE CER TIFICATE D ATA SHEET (Give No. and AIRW ORTHINES S DIRECTIVES (Check if all applicable A D's c ompli ed wi th and giv e the number of

the l ast A D SUP PLEME NT av ailable in the biweekly s eries as of the date of applic ation) 

96- 23

issued or renewed)

N/A

 No.)

Revision No.)

H3W E Rev 2

 14 CF R part 121 C ERTIFICATE H OLDER (Give Certificate No.)

A. REGISTE RED OW NER (A s show n on c ertifi cate of airc raft r egistr ation)

V. FAA 

REPRESENTATIVE 

CERTIFICATION

I. AIRCRAFT

DESCRIPTION III. OWNER'S CERTIFICATION

IV. INSPECTION 

AGENCY 

VERIFICATION

A

B

X STANDARD AIRW ORTHINESS CERTIFICATE (Indicate category)

SPECIAL AIR W ORTHINESS CERTIFICATE (Check appropriate items)

1. REGISTR ATION MARK

 N34562

APPLICAT ION IS H EREBY MA DE FOR: (Check applicabl e items)

2. AIRCRAFT BU ILDER'S NAME (Make)

 Hughes

3. AIRCRAFT MODEL DE SIGNATION FAA CODING

 369A

4. YR. MFR.

 1966

7. ENGINE MODEL DE SIGNATION

 250- C10B

10. PRO PELLER MODEL DESIG NATION

 N/A IMPORT

11. AIRC RAFT IS (Check if appl icable)

DATE DISTRICT OFFICE DESIGNEE'S SIG NATURE AND NO. FAA INSPECTOR 'S SIGNATURE

 (Check ALL appli cable bloc ks in item s A and B)

A. I find that the aircr aft desc ribed in Sec tion I or VII meets requirements for

X X

NAME

Helicopter Operations , Inc

ADDRESS 

2345 Perimeter Drive

Stockton, C ali for nia 94044

B. AIRCRA FT CE RTIFICATIO N BAS IS (C heck appli cable bloc ks and complete items as indic ated)

X

C. AIRCRAFT OPERATION A ND MAINTENANCE RECORDS

CHECK IF RECORDS IN

 COMPLIANCE W ITH 

14 CF R section 91.417

TOTAL AIRFRAME HOURS

2852:00 3

DATE OF APPLICATION

11/25/96

D. CERTIFICATION - I hereby certify that I am the regi ster ed owner (or his agent) of the aircr aft desc ribed above, that the ai rcraft i s registered with the Federal Av iati on A dministr ation in acc ordance with

Title 49 of the U nited States Code 44101 et seq. and appli cabl e Federal Av iati on R egul ations, and that the air craft has been i nspected and is airw orthy and el igible for the airworthi ness cer tifi cate

requested.

A. THE AIRCRAFT DES CRIBED ABOVE HAS B EEN IN SPECTED AND FOUND AIRW OR THY BY : (Complete this section only if 14 CFR part 21 .183( d) applies).

NAME AND T ITLE (Print or type)

James J. J ones, General M anager

SIGNATURE

DATE TITLE SIGNATURE

INSTRUCTIONS - Print or type. Do not write in shaded areas; these are for FAA

use only. Subm it original only to an authorized FAA Representative. If additional

space is required, use attachm ent. For special flight perm its com plete Sections

II, VI, and VII as applicable.

B. Inspecti on for a special fli ght permit under Sec tion VII

 was c onducted by:

6. ENGINE BUILDER 'S NAME (Make)

 Al lison

9. PROP ELLER B UILDER' S NAME (Make)

 N/A

5. AIRCR AFT SER IAL NO.

 1332

8. NUMBER OF ENGINES

 1

IF DEALER, CHECK HERE

AIRCRAFT LISTING (Gi ve page number(s))

N/A

SUPPLEMENTAL TYPE CERTIFICAT E (Li st number of each ST C inc orpor ated)

N/A

AIRCRAFT MANUFA CTURER (Give name or firm) 

U.S. D epartment

of Tr ansportation

Federal Aviation

Administration

Certificate No.)

O.M .B. No. 2120-0018

X NORMAL UTILITY ACROBATIC TRANSPORT COMMUTER BALLOON

FAA Form 8130-6 (5-01) Supersedes Previous Edition NSN: 0052-00-024-7006

C MULTIPLE AIR W ORTHINESS CERTIFICATE (Check ABOVE " Restr icted Oper ation" and "Standard" or "Limi ted" as applicable.)

SPECIAL FLIGHT PERMIT (Indi cate 

oper ati on to be conduc ted, then

 complete S ecti on V I or VII as 

applicable on rev erse side)

LIMITED

PROVIS IONAL (Indicate class)

RESTRICTED (Indi cate operation( s) to

 be c onducted)

AGRICULTURE AN D PEST CONTROL

FOREST (W ildlife c onservation)

CLAS S I

CLAS S II

AERIAL

PATRO LLING

 AERIAL ADVER TISING

 WEATHER CONTROL

AMATEUR BUILT

CREW TRAINING

EXHIBITION

MARKET SURVEY

DELIVERIN G OR EX PORTING

TO SHOW COMPLIAN CE W ITH THE CFR

CUSTOMER DEMONSTRATION FLIGHTS

PRODUCTION FLIGHT TESTING

FERRY FLIGHT FOR R EPAIRS, A LTERATION S, MAINT ENANCE, O R STORAGE

EVACUATE FROM AREA OF IMPE NDING DANGER

OPERATION IN EX CESS OF MAX IMUM CERTIF ICATED TAKE -OFF W EIGHT

RESEARCH AND DEVELOPMENT

EXPERIM ENTAL (Indicate operati on(s) AIR RACING to be c onducted)

OTHER (Specify)

OPERATING (Primary Category) KIT BUILT AIRCRAFT 

PRIMARY

FAA INSPECTOR

14 CFR par t 65

FAA DE SIGNEE

14 CFR part 121 OR 135 14 CFR part 145

THE CERTIFICA TE REQUESTED

AMENDMENT OR MODIFICATION OF CURRENT AIRW ORTHINESS CERTIFICATE

CERTIFICATE HOLDER UNDER

1 OTHER

4 1

3 6

4

2

5

3

4

 8

3

6

3

2

5

1

2

4

1

0

1

4

0

7

6

4

3

2

1

5

7

2

5

6

5

2
11/06/01 AC 21-12B

Appendix 1

Page 5

FIGURE 5. SAMPLE FAA FORM 8130-6, APPLICATION FOR A STANDARD

AIRWORTHINESS CERTIFICATE – AIRCRAFT BUILT FROM SPARE AND SURPLUS

PARTS (NO PREVIOUS U.S. AIRWORTHINESS CERTIFICATE ISSUED)

(FACE SIDE ONLY)

 APPLICATION FOR

AIR W OR TH IN ESS

CERTIFICATE

II. CERTIFICATION REQUESTED

EXPERIM EN TAL ONLY (Enter hours flown s ince la st cert ificate

CERTIFICATED M ECHANIC (Give CERTIFICATED R EPAIR STATION (Give Certificate

AIRCRAFT SPECI FICATION O R TYPE CER TIFICATE D ATA SHEET (Give No. and AIRW ORTHINES S DIRECTIVES (Check if all ap plica ble A D's c om pli ed wi th an d giv e the num b er of

the l ast A D SUP PLEM E NT av ailab le in the biwee kly s eries as o f the date of a pplic ation ) 

96- 23

issued or re newed)

N/A

 No.)

Revision No.)

H-1, R ev. 36

 14 CF R part 121 C ERTIFICATE H OLDER (Give

Certificate No.)

A. REGISTE RED OW NER (A s show n on c ertifi cate o f airc raft r egistr ation)

V. FAA 

REPRESENTATIVE 

CERTIFICATION

I. AIRCRAFT

DESCRIPTION III. OWNER'S CERTIFICATION

IV. INSPECTION 

AGENCY 

VERIFICATION

A

B

X STANDARD AIRW ORTHINESS CERTIFICATE (Ind icate cate gory)

SPECIAL AIR W ORTHINESS CERTIFICATE (Check approp riate item s)

1. REGISTR ATION M ARK

 N 6934M

APPLICAT ION IS H EREBY M A DE FOR: (Check a pplicabl e item s)

2. AIRCRAFT BU ILDER'S NAM E (M ake)

 S mith

3. AIRCRAFT M ODEL DE SIGNATION FAA CODING

 C-172M

4. YR. M FR.

 19 80

7. ENGINE M ODEL DE SIGNATION

 0 -32 0-B

10. PRO PELLER M ODEL DESIG NATION

 1C16 0/CTM IM PORT 

11. AIRC RAFT IS (Check if appl icable)

DATE DISTRICT OFFICE DESIGNEE'S SIG NATURE AND NO. FAA INSPECTOR 'S SIGNATURE

 (Check ALL appli cable bloc ks in item s A a nd B)

A. I fin d th at t he a ircr aft desc ribe d in Sec tion I o r VI I me ets requ irem ents for

X X

NAME

John R. S mith

ADDRESS 

6224 Arb or W ay

Spring fie ld,Ten nes see 70 653

B. AIRCRA FT CE RTIFI CATIO N BAS IS (C heck appli cable bloc ks an d com plete item s as indic ated)

X

C. AIRCRAFT OPERATION A ND M AINTENANCE RECORDS

CHECK IF RECORDS IN

 COM PLIANCE W ITH 

14 CF R se ctio n 91 .417

TOTAL AIRFRAM E HOURS

6.5 3

DATE OF APPLI CATION

11/2 5/96

D. CERTIFICATION - I hereby certify that I am the regi ster ed o wner (or his age nt) of t he a ircr aft desc ribe d ab ove, tha t th e ai rcra ft i s re gist ered wit h th e Fe dera l Av iati on A dmin istr atio n in acc orda nce with

Title 49 of th e U nit ed Sta tes Co de 441 01 et se q . and appli cabl e Fe dera l Av iati on R egul atio ns, and that the air craf t ha s be en i nspe cted and is airw orth y an d el igib le f or t he a irwo rthi ness cer tifi cate

requ ested.

A. THE AIRCRAFT DES CRIBED ABOVE HAS B EEN IN SPECTE D AND FOUND AIRW OR THY BY : (Com plete this sectio n only if 14 CFR p art 21 .183( d) app lies).

NAM E AND T ITLE (Prin t or type)

John R. Sm ith, Owner

SIGNATURE

DATE TITLE SIGNATURE

INSTRUCTIONS - Print or type. D o not w rite in shaded areas; these are for F AA

use only. Subm it original only to an authorized F AA R epresentative. If additional

space is required, use attachm ent. F or special flight perm its com plete Sections

II, VI, and VII as applicable.

B. Insp ecti on f or a spe cial fli ght perm it u nder Sec tion VII

 wa s c ond ucted by:

6. ENGINE BUILDER 'S NAM E (M ake)

 Lyco ming

9. PROP ELLER B UILDER' S NAM E (M ake)

 M c Cauley

5. AIRCR AFT SER IAL NO.

 Smi th 001

8. NUM BER OF ENGINES

 One

IF DEALER, CHECK HERE

AIRCRAFT LISTI NG (Gi ve pag e numb er(s))

N/A

SUPPLEM ENTAL TYPE CERTI FICAT E (Li st nu mber of ea ch ST C inc orpor ated)

N/A

AIRCRAFT M ANUFA CTURER (Give n ame or firm) 

U.S. D epa rtm ent

of Tr ansp orta tion

Federal Aviation

Administration

Certificate No.)

O.M .B. N o. 2120-0018

X NORMAL UTILITY ACROBATIC TRANSPORT COMMUTER BALLOON

FAA Form 8130-6 (5-01) Supersedes Previous Edition NSN: 0052-00-024-7006

C M ULTIPLE AIR W ORTHINESS CERTIFICATE (Check ABOVE " Restr icted Oper ation " and "Sta ndard " or "Lim i ted" as ap plica ble.)

SPECIAL FLIGHT PERM IT (Indi cate 

oper ati on to be con duc ted , t hen

 com ple te S ecti on V I or VII as 

applica ble o n rev erse side)

LIM ITED

PROVIS IONAL (Indicat e class)

RESTRICTED (Indi cate opera tion( s) to

 be c ond ucted)

AGRICULTURE AN D PEST CONTROL

FOREST (W ildlife c onservation)

CLAS S I

CLAS S II

AERIAL

PATRO LLING

 AERIAL ADVER TISING

 W EATHER CONTROL

AM ATEUR BUILT

CREW TRAINING

EXHIBITION

MARKET SURVEY

DELIVERIN G OR EX PORTING

TO SHOW COM PLIAN CE W ITH THE CFR

CUSTOM ER DEM ONSTRATION FLIGHTS

PRODUCTION FL IGHT TESTING

FERRY FLI GHT FOR R EPAIRS, A LTERATION S, M AINT ENANCE, O R STORAGE

EVACUATE FROM AREA OF IM PE NDING DANGER

OPERATION IN EX CESS OF M AX IM UM CERTIF ICATED TAKE -OFF W EIGHT

RESEARCH AND DEVELOPM ENT

EXPERIM ENTAL (Indica te op erati on(s) AIR RACING to b e c ond ucted)

OTHER (Specify)

OPERATING (Prim ary Category) KIT BUILT AIRCRAFT 

PRIM ARY

FAA INSPECTOR

14 CFR par t 65

FAA DE SIGNEE

14 CFR part 121 OR 135 14 CFR pa rt 145

THE CERTIFICA TE REQUESTED

AM ENDM ENT OR M ODIFICATION OF CURRENT AIRW ORTHINESS CERTIFICATE

CERTIFICATE HOLDER UNDER

1 OTHER

4 1

3 6

4

2

5

3

4

 8

3

6

3

2

5

1

2

4

1

0

1

4

0

7

6

4

3

2

1

5

7

2

5

6

5

2
AC 21-12B 11/06/01

Appendix 1

Page 6

FIGURE 6. SAMPLE FAA FORM 8130-6, APPLICATION FOR A SPECIAL

AIRWORTHINESS CERTIFICATE – PRIMARY CATEGORY AIRCRAFT CERTIFICATED

UNDER SECTION 21.184(a)

(FACE SIDE ONLY)

APPLICATION FOR

AIR W OR TH IN ESS

CERTIFICATE

II. CERTIFICATION REQUESTED

EXPERIM EN TAL ONLY (Enter hours flown s ince la st cert ificate

CERTIFICATED M ECHANIC (Give CERTIFICATED R EPAIR STATION (Give Certificate

AIRCRAFT SPECI FICATION O R TYPE CER TIFICATE D ATA SHEET (Give No. and AIRW ORTHINES S DIRECTIVES (Check if all ap plica ble A D's c om pli ed wi th an d giv e the num b er of

the l ast A D SUP PLEM E NT av ailab le in the biwee kly s eries as o f the date of a pplic ation ) 

96- 23

issued or re newed)

 No.)

Revision No.)

CE785

 14 CF R part 121 C ERTIFICATE H OLDER (Give

Certificate No.)

A. REGISTE RED OW NER (A s show n on c ertifi cate o f airc raft r egistr ation)

V. FAA 

REPRESENTATIVE 

CERTIFICATION

I. AIRCRAFT

DESCRIPTION III. OWNER'S CERTIFICATION

IV. INSPECTION 

AGENCY 

VERIFICATION

A

B X

STANDARD AIRW ORTHINESS CERTIFICATE (Ind icate cate gory)

SPECIAL AIR W ORTHINESS CERTIFICATE (Check approp riate item s)

1. REGISTR ATION M ARK

 N2EZ

APPLICAT ION IS H EREBY M A DE FOR: (Check a pplicabl e item s)

2. AIRCRAFT BU ILDER'S NAM E (M ake)

 Fl ight Corp.

3. AIRCRAFT M ODEL DE SIGNATION FAA CODING

 F-C-1A

4. YR. M FR.

 96

7. ENGINE M ODEL DE SIGNATION

 1 0-36 0-ES

10. PRO PELLER M ODEL DESIG NATION

 2A 34C 209 IM PORT

11. AIRC RAFT IS (Check if appl icable)

DATE DISTRICT OFFICE DESIGNEE'S SIG NATURE AND NO. FAA INSPECTOR 'S SIGNATURE

 (Check ALL appli cable bloc ks in item s A a nd B)

A. I fin d th at t he a ircr aft desc ribe d in Sec tion I o r VI I me ets requ irem ents for

X X

NAME

Flight Corp.

ADDRESS

10 La ne A ve

Doby, TX 78 907

B. AIRCRA FT CE RTIFI CATIO N BAS IS (C heck appli cable bloc ks an d com plete item s as indic ated)

X

C. AIRCRAFT OPERATION A ND M AINTENANCE RECORDS

CHECK IF RECORDS IN

 COM PLIANCE W ITH 

14 CF R se ctio n 91 .417

TOTAL AIRFRAM E HOURS

2.1 3

DATE OF APPLI CATION

11/2 5/96

D. CERTIFICATION - I hereby certify that I am the regi ster ed o wner (or his age nt) of t he a ircr aft desc ribe d ab ove, tha t th e ai rcra ft i s re gist ered wit h th e Fe dera l Av iati on A dmin istr atio n in acc orda nce with

Title 49 of th e U nit ed Sta tes Co de 441 01 et se q . and appli cabl e Fe dera l Av iati on R egul atio ns, and that the air craf t ha s be en i nspe cted and is airw orth y an d el igib le f or t he a irwo rthi ness cer tifi cate

requ ested.

A. THE AIRCRAFT DES CRIBED ABOVE HAS B EEN IN SPECTE D AND FOUND AIRW OR THY BY : (Com plete this sectio n only if 14 CFR p art 21 .183( d) app lies).

NAM E AND T ITLE (Prin t or type)

Joe Qu ality, Direc tor QA

SIGNATURE

DATE TITLE SIGNATURE

INSTRUCTIONS - Print or type. D o not w rite in shaded areas; these are for F AA

use only. Subm it original only to an authorized F AA R epresentative. If additional

space is required, use attachm ent. F or special flight perm its com plete Sections

II, VI, and VII as applicable.

B. Insp ecti on f or a spe cial fli ght perm it u nder Sec tion VII

 wa s c ond ucted by:

6. ENGINE BUILDER 'S NAM E (M ake)

 TCM 

9. PROP ELLER B UILDER' S NAM E (M ake)

 M c Cauley

5. AIRCR AFT SER IAL NO.

 F0 002

8. NUM BER OF ENGINES

 One

IF DEALER, CHECK HERE

AIRCRAFT LISTI NG (Gi ve pag e numb er(s))

N/A

SUPPLEM ENTAL TYPE CERTI FICAT E (Li st nu mber of ea ch ST C inc orpor ated)

N/A

AIRCRAFT M ANUFA CTURER (Give n ame or firm) 

U.S. D epa rtm ent

of Tr ansp orta tion

Federal Aviation

Administration

Certificate No.)

OMB No. 2120-0018

NORMAL UTILITY ACROBATIC TRANSPORT COMMUTER BALLOON

FAA Form 8130-6 (5-01) Supersedes Previous Edition NSN: 0052-00-024-7006

C M ULTIPLE AIR W ORTHINESS CERTIFICATE (Check ABOVE " Restr icted Oper ation " and "Sta ndard " or "Lim i ted" as ap plica ble.)

SPECIAL FLIGHT PERM IT (Indi cate 

oper ati on to be con duc ted , t hen

 com ple te S ecti on V I or VII as 

applica ble o n rev erse side)

LIM ITED

PROVIS IONAL (Indicat e class)

RESTRICTED (Indi cate opera tion( s) to

 be c ond ucted)

AGRICULTURE AN D PEST CONTROL

FOREST (W ildlife c onservation)

CLAS S I

CLAS S II

AERIAL

PATRO LLING

 AERIAL ADVER TISING

 W EATHER CONTROL

AM ATEUR BUILT

CREW TRAINING

EXHIBITION

MARKET SURVEY

DELIVERIN G OR EX PORTING

TO SHOW COM PLIAN CE W ITH THE CFR

CUSTOM ER DEM ONSTRATION FLIGHTS

PRODUCTION FL IGHT TESTING

FERRY FLI GHT FOR R EPAIRS, A LTERATION S, M AINT ENANCE, O R STORAGE

EVACUATE FROM AREA OF IM PE NDING DANGER

OPERATION IN EX CESS OF M AX IM UM CERTIF ICATED TAKE -OFF W EIGHT

RESEARCH AND DEVELOPM ENT

AIR RACING EXPERIM ENTAL (Indica te op erati on(s)

 to b e c ond ucted)

OTHER (Specify)

OPERATING (Prim ary Category) KIT BUILT AIRCRAFT 

X PRIM ARY

FAA INSPECTOR

14 CFR par t 65

FAA DE SIGNEE

14 CFR part 121 OR 135 14 CFR pa rt 145

THE CERTIFICA TE REQUESTED

AM ENDM ENT OR M ODIFICATION OF CURRENT AIRW ORTHINESS CERTIFICATE

CERTIFICATE HOLDER UNDER

1 OTHER

4 1

3 6

4

2

5

3

4

 8

3

6

3

2

5

1

2

4

1

0

1

4

0

7

6

4

3

2

1

5

7

2

5

6

5

2
11/06/01 AC 21-12B

Appendix 1

Page 7

FIGURE 7. SAMPLE FAA FORM 8130-6, APPLICATION FOR A SPECIAL

AIRWORTHINESS CERTIFICATE – LIMITED CATEGORY

(FACE SIDE ONLY)

APPLICATION FOR

AIR W OR THINESS

CERTIFICATE

II. CERTIFICATION REQUESTED

EXPERIMEN TAL ONLY (Enter hours flown s ince last certificate

CERTIFICATED M ECHANIC (Give CERTIFICATED R EPAIR STATION (Give Certificate

AIRCRAFT SPECI FICATION O R TYPE CER TIFICATE D ATA SHEET (Give No. and AIRW ORTHINES S DIRECTIVES (Check if all applica ble A D's c ompli ed wi th and giv e the numb er of

the l ast A D SUP PLEM E NT av ailab le in the biwee kly s eries as of the date of a pplic ation) 

 96 -23

issued or renewed)

N/A

 No.)

Revision No.)

AL-33 Rev.1

 14 CF R part 121 C ERTIFICATE H OLDER (Give Certificate No.)

A. REGISTE RED OW NER (A s show n on c ertifi cate of airc raft r egistr ation)

V. FAA 

REPRESENTATIVE 

CERTIFICATION

I. AIRCRAFT

DESCRIPTION III. OWNER'S CERTIFICATION

IV. INSPECTION 

AGENCY 

VERIFICATION

A

B X

STANDARD AIRW ORTHINESS CERTIFICATE (Indicate cate gory)

SPECIAL AIR W ORTHINESS CERTIFICATE (Check appropriate item s)

1. REGISTR ATION M ARK

 N1 256

APPLICAT ION IS H EREBY M A DE FOR: (Check applicabl e item s)

2. AIRCRAFT BU ILDER'S NAME (M ake)

 Martin

3. AIRCRAFT M ODEL DE SIGNATION FAA CODING

 B -26C

4. YR. MFR.

 19 43

7. ENGINE M ODEL DE SIGNATION

 R- 2800- 83AM B

10. PRO PELLER MODEL DESIG NATION

 42E60-7/689 5-8 IMPORT

11. AIRC RAFT IS (Check if appl icable)

DATE DISTRICT OFFICE DESIGNEE'S SIG NATURE AND NO. FAA INSPECTOR 'S SIGNATURE

 (Check ALL appli cable bloc ks in item s A and B)

A. I fin d th at t he a ircr aft desc ribe d in Sec tion I o r VI I me ets requ irem ents for

X X

NAME

Gas Tran smis sion Company

ADDRESS

1216 W est 48 th Str eet

Dallas, Tex as 64072

B. AIRCRA FT CE RTIFICATIO N BAS IS (C heck appli cable bloc ks and com plete items as indic ated)

X

C. AIRCRAFT OPERATION A ND M AINTENANCE RECORDS

CHECK IF RECORDS IN

 COMPLIANCE W ITH 

14 CF R se ctio n 91 .417

TOTAL AIRFRAM E HOURS

12,632 3

DATE OF APPLI CATION

11/20/96

D. CERTIFICATION - I hereby certify that I am the regi ster ed owner (or his age nt) of the aircr aft desc ribed ab ove, tha t the ai rcraft i s registered with the Federa l Av iati on A dmin istr atio n in acc ordance with

Title 49 of the U nited Sta tes Co de 44101 et seq . and appli cabl e Fe dera l Av iati on R egul ations, and that the air craft ha s be en i nspected and is airw orthy and el igible for the airworthi ness cer tifi cate

requested.

A. THE AIRCRAFT DES CRIBED ABOVE HAS B EEN IN SPECTE D AND FOUND AIRW OR THY BY : (Com plete this section only if 14 CFR p art 21 .183( d) applies).

NAM E AND T ITLE (Prin t or type)

George Brow n, P resi dent

SIGNATURE

DATE TITLE SIGNATURE

IN STR UC TION S - Print or type. Do not w rite in shaded areas; these are for FAA

use only. Subm it original only to an authorized FAA Representative. If additional

space is required, use attachm ent. For special flight perm its com plete Sections

II, VI, and VII as applicable.

B. Inspecti on for a special fli ght perm it u nder Sec tion VII

 wa s c ond ucted by:

6. ENGINE BUILDER 'S NAM E (Make)

 P&W

9. PROP ELLER B UILDER' S NAME (Make)

 Ha mil ton Standard

5. AIRCR AFT SER IAL NO.

 22 56

8. NUMBER OF ENGINES

 Two

IF DEALER, CHECK HERE

AIRCRAFT LISTING (Gi ve page numb er(s))

N/A

SUPPLEMENTAL TYPE CERTIFICAT E (Li st number of each ST C inc orpor ated)

N/A

AIRCRAFT M ANUFA CTURER (Give name or firm) 

U.S. D epa rtment

of Tr ansportation

Federal Aviation

Administration

Certificate No.)

O.M .B. N o. 2120-0018

NORMAL UTILITY ACROBATIC TRANSPORT COM MUTER BALLOON

FAA Form 8130-6 (5-01) Supersedes Previous Edition NSN: 0052-00-024-7006

C MULTIPLE AIR W ORTHINESS CERTIFICATE (Check ABOVE " Restr icted Oper ation " and "Standard " or "Limi ted" as ap plicable.)

X

SPECIAL FLIGHT PERM IT (Indi cate 

oper ati on to be conduc ted, t hen

 com plete S ecti on V I or VII as 

applicable on rev erse side)

LIMITED

PROVIS IONAL (Indicate class)

RESTRICTED (Indi cate operation( s) to

 be c onducted)

AGRICULTURE AN D PEST CONTROL

FOREST (W ildlife c onservation)

CLAS S I

CLAS S II

AERIAL

PATRO LLING

 AERIAL ADVER TISING

 WEATHER CONTROL

AM ATEUR BUILT

CREW TRAINING

EXHIBITION

MARKET SURVEY

DELIVERIN G OR EX PORTING

TO SHOW COM PLIAN CE W ITH THE CFR

CUSTOM ER DEMONSTRATION FLIGHTS

PRODUCTION FLIGHT TESTING

FERRY FLIGHT FOR R EPAIRS, A LTERATION S, MAINT ENANCE, O R STORAGE

EVACUATE FROM AREA OF IM PE NDING DANGER

OPERATION IN EX CESS OF M AX IMUM CERTIF ICATED TAKE -OFF W EIGHT

RESEARCH AND DEVELOPMENT

EXPERIM ENTAL (Indica te operati on(s) AIR RACING to be c onducted)

OTHER (Specify)

OPERATING (Prim ary Category) KIT BUILT AIRCRAFT 

PRIM ARY

FAA INSPECTOR

14 CFR par t 65

FAA DE SIGNEE

14 CFR part 121 OR 135 14 CFR pa rt 145

THE CERTIFICA TE REQUESTED

AM ENDM ENT OR MODIFICATION OF CURRENT AIRW ORTHINESS CERTIFICATE

CERTIFICATE HOLDER UNDER

1 OTHER

4 1

3 6

4

2

5

3

4

 8

3

6

3

2

5

1

2

4

1

0

1

4

0

7

6

4

3

2

1

5

7

2

5

6

5

2
AC 21-12B 11/06/01

Appendix 1

Page 8

FIGURE 8. SAMPLE FAA FORM 8130-6, APPLICATION FOR A SPECIAL

AIRWORTHINESS CERTIFICATE – PROVISIONAL CATEGORY

(FACE SIDE ONLY)

APPLICATION FOR

AIRW ORTHINESS

CERTIFICATE

II. CERTIFICATION REQUESTED

EXPERIM EN TAL ONLY (Enter hours flown s ince last certificate

CERTIFICATED M ECHANIC (Give CERTIFICATED R EPAIR STATION (Give Certificate

AIRCRAFT SPECI FICATION O R TYPE CER TIFICATE D ATA SHEET (Give No. and AIRW ORTHINES S DIRECTIVES (Check if all applicable A D's c om pli ed wi th and giv e the num ber of

the l ast A D SUP PLEM E NT av ailable in the biweekly s eries as of the date of applic ation) 

96- 23

issued or renewed)

N/A

 No.)

Revision No.)

A1SO

 14 CF R part 121 C ERTIFICATE H OLDER (Give

Certificate No.)

A. REGISTE RED OW NER (A s show n on c ertifi cate of airc raft r egistr ation)

V. FAA 

REPRESENTATIVE 

CERTIFICATION

I. AIRCRAFT

DESCRIPTION III. OWNER'S CERTIFICATION

IV. INSPECTION 

AGENCY 

VERIFICATION

A

B X

STANDARD AIRW ORTHINESS CERTIFICATE (Ind icate cate gory)

SPECIAL AIR W ORTHINESS CERTIFICATE (Check appropriate item s)

1. REGISTR ATION M ARK

 N 502A

APPLICAT ION IS H EREBY M A DE FOR: (Check applicabl e item s)

2. AIRCRAFT BU ILDER'S NAM E (M ake)

 Lock heed-Georgia Co.

3. AIRCRAFT M ODEL DE SIGNATION FAA CODING

 382G

4. YR. M FR.

 1996

7. ENGINE M ODEL DE SIGNATION

 501- D22A

10. PRO PELLER M ODEL DESIG NATION

54H60- 91/54H 60- 117 IM PORT

11. AIRC RAFT IS (Check if appl icable)

DATE DISTRICT OFFICE DESIGNEE'S SIG NATURE AND NO. FAA INSPECTOR 'S SIGNATURE

 (Check ALL appli cable bloc ks in item s A and B)

A. I find that the aircr aft desc ribed in Sec tion I or VII meets requirem ents for

X X

NAME

Lockheed Georgia Co.

ADDRESS

M arietta, G eor gia 30060

B. AIRCRA FT CE RTIFI CATIO N BAS IS (C heck appli cable bloc ks and com plete item s as indic ated)

X

C. AIRCRAFT OPERATION A ND M AINTENANCE RECORDS

CHECK IF RECORDS IN

 COM PLIANCE W ITH 

14 CF R section 91.417

TOTAL AIRFRAM E HOURS

10.2 3

DATE OF APPLI CATION

11/25/96

D. CERTIFICATION - I hereby certify that I am the regi ster ed owner (or his agent) of the aircr aft desc ribed above, that the ai rcraft i s registered with the Federal Av iati on A dministr ation in acc ordance with

Title 49 of the U nited States Code 44101 et se q . and appli cabl e Federal Av iati on R egul ations, and that the air craft has been i nspected and is airw orthy and el igible for the a irworthi ness cer tifi cate

requested.

A. THE AIRCRAFT DES CRIBED ABOVE HAS B EEN IN SPECTE D AND FOUND AIRW OR THY BY : (Com plete this sectio n only if 14 CFR p art 21 .183( d) applies).

NAM E AND T ITLE (Prin t or type)

James A. Jone s Vi ce P resi dent Eng inee ring

SIGNATURE

DATE TITLE SIGNATURE

INSTRUCTIONS - Print or type. D o not w rite in shaded areas; these are for FAA

use only. Subm it original only to an authorized FAA R epresentative. If additional

space is required, use attachm ent. For special flight perm its com plete Sections

II, VI, and VII as applicable.

B. Inspecti on for a special fli ght perm it under Sec tion VII

 was c onducted by:

6. ENGINE BUILDER 'S NAM E (M ake)

 

 Al lison

9. PROP ELLER B UILDER' S NAM E (M ake)

 H amil ton- Stan dard

5. AIRCR AFT SER IAL NO.

 4387

8. NUM BER OF ENGINES

 Four

IF DEALER, CHECK HERE

AIRCRAFT LISTI NG (Gi ve pag e numb er(s))

N/A

SUPPLEM ENTAL TYPE CERTI FICAT E (Li st nu mber of ea ch ST C inc orpor ated)

N/A

 AIR CRAFT M ANU FACTURER ( Give name or firm) 

U.S. D epartm ent

of Tr ansportation

Federal Aviation

Administration

Certificate No.)

O.M .B. N o. 2120-0018

NORMAL UTILITY ACROBATIC TRANSPORT COMMUTER BALLOON

FAA Form 8130-6 (5-01) Supersedes Previous Edition NSN:0052-00-024-7006

C M ULTIPLE AIR W ORTHINESS CERTIFICATE (Check ABOVE " Restr icted Oper ation" and "Standard" or "Lim i ted" as applicable.)

X

SPECIAL FLIGHT PERM IT (Indi cate 

oper ati on to be con duc ted , t hen

 com plete S ecti on V I or VII as 

applicable on rev erse side)

LIM ITED

PROVIS IONAL (Indicat e class)

RESTRICTED (Indi cate operation( s) to

 be c onducted)

X

AGRICULTURE AN D PEST CONTROL

FOREST (W ildlife c onservation)

CLAS S I

CLAS S II

AERIAL

PATRO LLING

 AERIAL ADVER TISING

 W EATHER CONTROL

AM ATEUR BUILT

CREW TRAINING

EXHIBITION

MARKET SURVEY

DELIVERIN G OR EX PORTING

TO SHOW COM PLIAN CE W ITH THE CFR

CUSTOM ER DEM ONSTRATION FLIGHTS

PRODUCTION FL IGHT TESTING

FERRY FLI GHT FOR R EPAIRS, A LTERATION S, M AINT ENANCE, O R STORAGE

EVACUATE FROM AREA OF IM PE NDING DANGER

OPERATION IN EX CESS OF M AX IM UM CERTIF ICATED TAKE -OFF W EIGHT

RESEARCH AND DEVELOPM ENT

AIR RACING EXPERIM ENTAL (Indicate operati on(s)

 to be c onducted)

OTHER (Specify)

OPERATING (Prim ary Category) KIT BUILT AIRCRAFT 

PRIM ARY

FAA INSPECTOR

14 CFR par t 65

FAA DE SIGNEE

14 CFR part 121 OR 135 14 CFR part 145

THE CERTIFICA TE REQUESTED

AM ENDM ENT OR M ODIFICATION OF CURRENT AIRW ORTHINESS CERTIFICATE

CERTIFICATE HOLDER UNDER

1 OTHER

4 1

3 6

4

2

5

3

4

 8

3

6

3

2

5

1

2

4

1

0

1

4

0

7

6

4

3

2

1

5

7

2

5

6

5

2
11/06/01 AC 21-12B

Appendix 1

Page 9

FIGURE 9. SAMPLE FAA FORM 8130-6, APPLICATION FOR A SPECIAL

AIRWORTHINESS CERTIFICATE – RESTRICTED CATEGORY

(FACE SIDE ONLY)

APPLICATION FOR

AIRW ORTHINESS

CERTIFICATE

II. CERTIFICATION REQUESTED

EXPERIM EN TAL ONLY (Enter hours flown s ince last certificate

CERTIFICATED M ECHANIC (Give CERTIFICATED R EPAIR STATION (Give Certificate

AIRCRAFT SPECI FICATION O R TYPE CER TIFICATE D ATA SHEET (Give No. and AIRW ORTHINES S DIRECTIVES (Check if all applicable A D's c om pli ed wi th and giv e the num ber of

the l ast A D SUP PLEM E NT av ailable in the biweekly s eries as of the date of applic ation) 

96- 23

issued or renewed)

N/A

 No.)

Revision No.)

A4SW R ev. 5

 14 CF R part 121 C ERTIFICATE H OLDER (Give

Certificate No.)

A. REGISTE RED OW NER (A s show n on c ertifi cate of airc raft r egistr ation)

V. FAA 

REPRESENTATIVE 

CERTIFICATION

I. AIRCRAFT

DESCRIPTION III. OWNER'S CERTIFICATION

IV. INSPECTION 

AGENCY 

VERIFICATION

A

B X

STANDARD AIRW ORTHINESS CERTIFICATE (Ind icate cate gory)

SPECIAL AIR W ORTHINESS CERTIFICATE (Check appropriate item s)

1. REGISTR ATION M ARK

 N7777

APPLICAT ION IS H EREBY M A DE FOR: (Check applicabl e item s)

2. AIRCRAFT BU ILDER'S NAM E (M ake)

 North Ameri can Rockwell

3. AIRCRAFT M ODEL DE SIGNATION FAA CODING

 S2R

4. YR. M FR.

 1950

7. ENGINE M ODEL DE SIGNATION

 R1340A N1(S 3H1)

10. PRO PELLER M ODEL DESIG NATION

 12D40- 305/EAC/AG 100-2 IM PORT

11. AIRC RAFT IS (Check if appl icable)

DATE DISTRICT OFFICE DESIGNEE'S SIG NATURE AND NO. FAA INSPECTOR 'S SIGNATURE

 (Check ALL appli cable bloc ks in item s A and B)

A. I find that the aircr aft desc ribed in Sec tion I or VII meets requirem ents for

X X

NAME 

John J J ones , R.B. J ones

DBA Crop Duster s, Inc.

ADDRESS

 Rt. 5

Greenvill e, M i ssiss ippi 38701

B. AIRCRA FT CE RTIFI CATIO N BAS IS (C heck appli cable bloc ks and com plete item s as indic ated)

X

C. AIRCRAFT OPERATION A ND M AINTENANCE RECORDS

CHECK IF RECORDS IN

 COM PLIANCE W ITH 

14 CF R section 91.417

TOTAL AIRFRAM E HOURS

2105 3

DATE OF APPLI CATION

11/25/96

D. CERTIFICATION - I hereby certify that I am the regi ster ed owner (or his agent) of the aircr aft desc ribed above, that the ai rcraft i s registered with the Federal Av iati on A dministr ation in acc ordance with

Title 49 of the U nited States Code 44101 et se q . and appli cabl e Federal Av iati on R egul ations, and that the air craft has been i nspected and is airw orthy and el igible for the a irworthi ness cer tifi cate

requested.

A. THE AIRCRAFT DES CRIBED ABOVE HAS B EEN IN SPECTE D AND FOUND AIRW OR THY BY : (Com plete this sectio n only if 14 CFR p art 21 .183( d) applies).

NAM E AND T ITLE (Prin t or type)

John J. Jones, Co-O wner

SIGNATURE

DATE TITLE SIGNATURE

INSTRUCTIONS - Print or type. D o not w rite in shaded areas; these are for FAA

use only. Subm it original only to an authorized FAA R epresentative. If additional

space is required, use attachm ent. For special flight perm its com plete Sections

II, VI, and VII as applicable.

B. Inspecti on for a special fli ght perm it under Sec tion VII

 was c onducted by:

6. ENGINE BUILDER 'S NAM E (M ake)

 P&W

9. PROP ELLER B UILDER' S NAM E (M ake)

 Ha mil ton St and ard

5. AIRCR AFT SER IAL NO.

 1916R

8. NUM BER OF ENGINES

 One

IF DEALER, CHECK HERE

AIRCRAFT LISTI NG (Gi ve pag e numb er(s))

N/A

SUPPLEM ENTAL TYPE CERTI FICAT E (Li st nu mber of ea ch ST C inc orpor ated)

N/A

AIRCRAFT M ANUFA CTURER (Give n ame or firm) 

U.S. D epartm ent

of Tr ansportation

Federal Aviation

Administration

Certificate No.)

O.M .B. N o. 2120-0018

NORMAL UTILITY ACROBATIC TRANSPORT COMMUTER BALLOON

FAA Form 8130-6 (5-01) Supersedes Previous Edition NSN: 0052-00-024-7006

C M ULTIPLE AIR W ORTHINESS CERTIFICATE (Check ABOVE " Restr icted Oper ation" and "Standard" or "Lim i ted" as applicable.)

X

SPECIAL FLIGHT PERM IT (Indi cate 

oper ati on to be con duc ted , t hen

 com plete S ecti on V I or VII as 

applicable on rev erse side)

LIM ITED

PROVIS IONAL (Indicat e class)

RESTRICTED (Indi cate operation( s) to

 be c onducted)

AGRICULTURE AN D PEST CONTROL

FOREST (W ildlife c onservation)

CLAS S I

CLAS S II

AERIAL

PATRO LLING

 AERIAL ADVER TISING

 W EATHER CONTROL

AM ATEUR BUILT

CREW TRAINING

EXHIBITION

MARKET SURVEY

DELIVERIN G OR EX PORTING

TO SHOW COM PLIAN CE W ITH THE CFR

CUSTOM ER DEM ONSTRATION FLIGHTS

PRODUCTION FL IGHT TESTING

X

FERRY FLI GHT FOR R EPAIRS, A LTERATION S, M AINT ENANCE, O R STORAGE

EVACUATE FROM AREA OF IM PE NDING DANGER

OPERATION IN EX CESS OF M AX IM UM CERTIF ICATED TAKE -OFF W EIGHT

RESEARCH AND DEVELOPM ENT

EXPERIM ENTAL (Indicate operati on(s) AIR RACING

 to be c onducted)

OTHER (Specify)

OPERATING (Prim ary Category) KIT BUILT AIRCRAFT 

PRIM ARY

FAA INSPECTOR

14 CFR par t 65

FAA DE SIGNEE

14 CFR part 121 OR 135 14 CFR part 145

THE CERTIFICA TE REQUESTED

AM ENDM ENT OR M ODIFICATION OF CURRENT AIRW ORTHINESS CERTIFICATE

CERTIFICATE HOLDER UNDER

1 OTHER

4 1

3 6

4

2

5

3

4

 8

3

6

3

2

5

1

2

4

1

0

1

4

0

7

6

4

3

2

1

5

7

2

5

6

5

2
AC 21-12B 11/06/01

Appendix 1

Page 10

FIGURE 10. SAMPLE FAA FORM 8130-6, APPLICATION FOR A SPECIAL

AIRWORTHINESS CERTIFICATE – EXPERIMENTAL CATEGORY AMATEUR-BUILT

(FACE SIDE ONLY)

APPLICATION FOR

AIRW ORTHINESS

CERTIFICATE

II. CERTIFICATION REQUESTED

EXPERIMEN TAL ONLY (Enter hours flown s ince last certificate

CERTIFICATED MECHANIC (Give CERTIFICATED R EPAIR STATION (Give Certificate

AIRCRAFT SPECIFICATION O R TYPE CER TIFICATE D ATA SHEET (Give No. and AIRW ORTHINES S DIRECTIVES (Check if all applicable A D's c ompli ed wi th and giv e the number of

the l ast A D SUP PLEME NT av ailable in the biweekly s eries as of the date of applic ation) 

96- 23

issued or renewed)

0.0

 No.)

Revision No.)

N/A

 14 CF R part 121 C ERTIFICATE H OLDER (Give Certificate No.)

A. REGISTE RED OW NER (A s show n on c ertifi cate of airc raft r egistr ation)

V. FAA 

REPRESENTATIVE 

CERTIFICATION

I. AIRCRAFT

DESCRIPTION III. OWNER'S CERTIFICATION

IV. INSPECTION 

AGENCY 

VERIFICATION

A

B X

STANDARD AIRW ORTHINESS CERTIFICATE (Indicate category)

SPECIAL AIR W ORTHINESS CERTIFICATE (Check appropriate items)

1. REGISTR ATION MARK

 N1234

APPLICAT ION IS H EREBY MA DE FOR: (Check applicabl e items)

2. AIRCRAFT BU ILDER'S NAME (Make)

 P ratt

3. AIRCRAFT MODEL DE SIGNATION FAA CODING

 B -3 

4. YR. MFR.

 1996

7. ENGINE MODEL DE SIGNATION

 A-65

10. PRO PELLER MODEL DESIG NATION

 N76AM -2-50 IMPORT

11. AIRC RAFT IS (Check if appl icable)

DATE DISTRICT OFFICE DESIGNEE'S SIG NATURE AND NO. FAA INSPECTOR 'S SIGNATURE

 (Check ALL appli cable bloc ks in item s A and B)

A. I find that the aircr aft desc ribed in Sec tion I or VII meets requirements for

X

NAME 

Howard D . Pratt

John J Smith Co- Owner

ADDRESS 

1120 W est Str eet

ST Louis , Mi ssouri 41346

B. AIRCRA FT CE RTIFICATIO N BAS IS (C heck appli cable bloc ks and complete items as indic ated)

X

C. AIRCRAFT OPERATION A ND MAINTENANCE RECORDS

CHECK IF RECORDS IN

 COMPLIANCE W ITH 

14 CF R section 91.417

TOTAL AIRFRAME HOURS

0.0 3

DATE OF APPLICATION

11/25/96

D. CERTIFICATION - I hereby certify that I am the regi ster ed owner (or his agent) of the aircr aft desc ribed above, that the ai rcraft i s registered with the Federal Av iati on A dministr ation in acc ordance with

Title 49 of the U nited States Code 44101 et seq. and appli cabl e Federal Av iati on R egul ations, and that the air craft has been i nspected and is airw orthy and el igible for the airworthi ness cer tifi cate

requested.

A. THE AIRCRAFT DES CRIBED ABOVE HAS B EEN IN SPECTE D AND FOUND AIRW OR THY BY : (Complete this section only if 14 CFR part 21 .183( d) applies).

NAME AND T ITLE (Print or type)

Howard D. Pratt, Co Owner

SIGNATURE

DATE TITLE SIGNATURE

INSTRUCTIONS - Print or type. Do not write in shaded areas; these are for FAA

use only. Subm it original only to an authorized FAA Representative. If additional

space is required, use attachm ent. For special flight perm its com plete Sections

II, VI, and VII as applicable.

B. Inspecti on for a special fli ght permit under Sec tion VII

 was c onducted by:

6. ENGINE BUILDER 'S NAME (Make)

 CMC

9. PROP ELLER B UILDER' S NAME (Make)

 Sensenich

5. AIRCR AFT SER IAL NO.

 001

8. NUMBER OF ENGINES

 One

IF DEALER, CHECK HERE

AIRCRAFT LISTING (Gi ve page number(s)) SUPPLEMENTAL TYPE CERTIFICAT E (Li st number of each ST C inc orpor ated)

AIRCRAFT MANUFA CTURER (Give name or firm) 

U.S. D epartment

of Tr ansportation

Federal Aviation

Administration

Certificate No.)

O.M .B. No. 2120-0018

NORMAL UTILITY ACROBATIC TRANSPORT COMMUTER BALLOON

FAA Form 8130-6 (5-01) Supersedes Previous Edition N SN: 0052-00-024-7006

C MULTIPLE AIR W ORTHINESS CERTIFICATE (Check ABOVE " Restr icted Oper ation" and "Standard" or "Limi ted" as applicable.)

SPECIAL FLIGHT PERMIT (Indi cate 

oper ati on to be conduc ted, then

 complete S ecti on V I or VII as 

applicable on rev erse side)

LIMITED

PROVIS IONAL (Indicate class)

RESTRICTED (Indi cate operation( s) to

 be c onducted)

AGRICULTURE AN D PEST CONTROL

FOREST (W ildlife c onservation)

CLAS S I

CLAS S II

AERIAL

PATRO LLING

 AERIAL ADVER TISING

 WEATHER CONTROL

AMATEUR BUILT

CREW TRAINING

EXHIBITION

MARKET SURVEY

DELIVERIN G OR EX PORTING

TO SHOW COMPLIAN CE W ITH THE CFR

CUSTOMER DEMONSTRATION FLIGHTS

PRODUCTION FLIGHT TESTING

FERRY FLIGHT FOR R EPAIRS, A LTERATION S, MAINT ENANCE, O R STORAGE

EVACUATE FROM AREA OF IMPE NDING DANGER

OPERATION IN EX CESS OF MAX IMUM CERTIF ICATED TAKE -OFF W EIGHT

RESEARCH AND DEVELOPMENT X

EXPERIM ENTAL (Indicate operati on(s) AIR RACING

 to be c onducted) X

OTHER (Specify)

OPERATING (Primary Category) KIT BUILT AIRCRAFT 

PRIMARY

FAA INSPECTOR

14 CFR par t 65

FAA DE SIGNEE

14 CFR part 121 OR 135 14 CFR part 145

THE CERTIFICA TE REQUESTED

AMENDMENT OR MODIFICATION OF CURRENT AIRW ORTHINESS CERTIFICATE

CERTIFICATE HOLDER UNDER

1 OTHER

4 1

3 6

4

2

5

3

4

 8

3

3

2

5

1

2

4

1

0

1

4

0

7

6

4

3

2

1

5

2

5

6

5

2
11/06/01 AC 21-12B

Appendix 1

Page 11

FIGURE 11. SAMPLE FAA FORM 8130-6, APPLICATION FOR A SPECIAL

AIRWORTHINESS CERTIFICATE – EXPERIMENTAL CATEGORY, NO PREVIOUS

EXPERIMENTAL CERTIFICATE ISSUED

(FACE SIDE ONLY)

APPLICATION FOR

AIR W OR TH IN ESS

CERTIFICATE

II. CERTIFICATION REQUESTED

EXPERIM EN TAL ONLY (Enter hours flown s ince last certificate

CERTIFICATED M ECHANIC (Give CERTIFICATED R EPAIR STATION (Give Certificate

AIRCRAFT SPECI FICATION O R TYPE CER TIFICATE D ATA SHEET (Give No. and AIRW ORTHINES S DIRECTIVES (Check if all applicable A D's c om pli ed wi th and giv e the num ber of

the l ast A D SUP PLEM E NT av ailable in the biweekly s eries as of the date of applic ation) 

96- 23

issued or renewed)

0.0

 No.)

Revision No.)

N/A

 14 CF R part 121 C ERTIFICATE H OLDER (Give

Certificate No.)

A. REGISTE RED OW NER (A s show n on c ertifi cate of airc raft r egistr ation)

V. FAA 

REPRESENTATIVE 

CERTIFICATION

I. AIRCRAFT

DESCRIPTION III. OWNER'S CERTIFICATION

IV. INSPECTION 

AGENCY 

VERIFICATION

A

B X

STANDARD AIRW ORTHINESS CERTIFICATE (Ind icate cate gory)

SPECIAL AIR W ORTHINESS CERTIFICATE (Check appropriate item s)

1. REGISTR ATION M ARK

 N5216

APPLICAT ION IS H EREBY M A DE FOR: (Check applicabl e item s)

2. AIRCRAFT BU ILDER'S NAM E (M ake)

 Boeing

3. AIRCRAFT M ODEL DE SIGNATION FAA CODING

 7 27 -2 28

4. YR. M FR.

 1968

7. ENGINE M ODEL DE SIGNATION

 JT8D-7

10. PRO PELLER M ODEL DESIG NATION

 N/A IM PORT

11. AIRC RAFT IS (Check if appl icable)

DATE DISTRICT OFFICE DESIGNEE'S SIG NATURE AND NO. FAA INSPECTOR 'S SIGNATURE

 (Check ALL appli cable bloc ks in item s A and B)

A. I find that the aircr aft desc ribed in Sec tion I or VII meets requirem ents for

X

NAME 

The Bo ein g C omp any

ADDRESS 

PO Bo x 37 07

Seattle, W ashington 98124

B. AIRCRA FT CE RTIFI CATIO N BAS IS (C heck appli cable bloc ks and com plete item s as indic ated)

X

C. AIRCRAFT OPERATION A ND M AINTENANCE RECORDS

CHECK IF RECORDS IN

 COM PLIANCE W ITH 

14 CF R section 91.417

TOTAL AIRFRAM E HOURS

5.51 3

DATE OF APPLI CATION

11/25/96

D. CERTIFICATION - I hereby certify that I am the regi ster ed owner (or his agent) of the aircr aft desc ribed above, that the ai rcraft i s registered with the Federal Av iati on A dministr ation in acc ordance with

Title 49 of the U nited States Code 44101 et se q . and appli cabl e Federal Av iati on R egul ations, and that the air craft has been i nspected and is airw orthy and el igible for the a irworthi ness cer tifi cate

requested.

A. THE AIRCRAFT DES CRIBED ABOVE HAS B EEN IN SPECTE D AND FOUND AIRW OR THY BY : (Com plete this sectio n only if 14 CFR p art 21 .183( d) applies).

NAM E AND T ITLE (Prin t or type)

R.B. Smith, Airworthiness C ertificati on M anager

SIGNATURE

DATE TITLE SIGNATURE

INSTRUCTIONS - Print or type. D o not w rite in shaded areas; these are for F AA

use only. Subm it original only to an authorized F AA R epresentative. If additional

space is required, use attachm ent. F or special flight perm its com plete Sections

II, VI, and VII as applicable.

B. Inspecti on for a special fli ght perm it under Sec tion VII

 was c onducted by:

6. ENGINE BUILDER 'S NAM E (M ake)

 P&W

9. PROP ELLER B UILDER' S NAM E (M ake)

 N/A

5. AIRCR AFT SER IAL NO.

 20540

8. NUM BER OF ENGINES

 T hree

IF DEALER, CHECK HERE

AIRCRAFT LISTI NG (Gi ve pag e numb er(s))

N/A

SUPPLEM ENTAL TYPE CERTI FICAT E (Li st nu mber of ea ch ST C inc orpor ated)

AIRCRAFT M ANUFA CTURER (Give n ame or firm) 

U.S. D epartm ent

of Tr ansportation

Federal Aviation

Administration

Certificate No.)

O.M .B. N o. 2120-0018

NORMAL UTILITY ACROBATIC TRANSPORT COMMUTER BALLOON

FAA Form 8130-6 (5-01) Supersedes Previous Edition NSN: 0052-00-024-7006

C M ULTIPLE AIR W ORTHINESS CERTIFICATE (Check ABOVE " Restr icted Oper ation" and "Standard" or "Lim i ted" as applicable.)

SPECIAL FLIGHT PERM IT (Indi cate 

oper ati on to be con duc ted , t hen

 com plete S ecti on V I or VII as 

applicable on rev erse side)

LIM ITED

PROVIS IONAL (Indicat e class)

RESTRICTED (Indi cate operation( s) to

 be c onducted)

AGRICULTURE AN D PEST CONTROL

FOREST (W ildlife c onservation)

CLAS S I

CLAS S II

AERIAL

PATRO LLING

 AERIAL ADVER TISING

 W EATHER CONTROL

AM ATEUR BUILT

CREW TRAINING

EXHIBITION

MARKET SURVEY

DELIVERIN G OR EX PORTING

TO SHOW COM PLIAN CE W ITH THE CFR

CUSTOM ER DEM ONSTRATION FLIGHTS

PRODUCTION FL IGHT TESTING

X

FERRY FLI GHT FOR R EPAIRS, A LTERATION S, M AINT ENANCE, O R STORAGE

EVACUATE FROM AREA OF IM PE NDING DANGER

OPERATION IN EX CESS OF M AX IM UM CERTIF ICATED TAKE -OFF W EIGHT

RESEARCH AND DEVELOPM ENT

AIR RACING EXPERIM ENTAL (Indicate operati on(s)

 to be c onducted) X

OTHER (Specify)

OPERATING (Prim ary Category) KIT BUILT AIRCRAFT 

PRIM ARY

FAA INSPECTOR

14 CFR par t 65

FAA DE SIGNEE

14 CFR part 121 OR 135 14 CFR part 145

THE CERTIFICA TE REQUESTED

AM ENDM ENT OR M ODIFICATION OF CURRENT AIRW ORTHINESS CERTIFICATE

CERTIFICATE HOLDER UNDER

1 OTHER

4 1

3 6

4

2

5

3

4

 8

3

6

3

2

5

1

2

4

1

0

1

4

0

7

6

4

3

2

1

5

7

2

5

6

5

2
AC 21-12B 11/06/01

Appendix 1

Page 12

FIGURE 12. SAMPLE FAA FORM 8130-6, APPLICATION FOR A SPECIAL

AIRWORTHINESS CERTIFICATE – EXPERIMENTAL CATEGORY

(FACE SIDE ONLY)

APPLICATION FOR

AIR W OR THINESS

CERTIFICATE

II. CERTIFICATION REQUESTED

EXPERIMEN TAL ONLY (Enter hours flown s ince last certificate

CERTIFICATED M ECHANIC (Give CERTIFICATED R EPAIR STATION (Give Certificate

AIRCRAFT SPECI FICATION O R TYPE CER TIFICATE D ATA SHEET (Give No. and AIRW ORTHINES S DIRECTIVES (Check if all applica ble A D's c ompli ed wi th and giv e the numb er of

the l ast A D SUP PLEM E NT av ailab le in the biwee kly s eries as of the date of a pplic ation) 

96- 23

issued or renewed)

22 .0

 No.)

Revision No.)

N/A

 14 CF R part 121 C ERTIFICATE H OLDER (Give Certificate No.)

A. REGISTE RED OW NER (A s show n on c ertifi cate of airc raft r egistr ation)

V. FAA 

REPRESENTATIVE 

CERTIFICATION

I. AIRCRAFT

DESCRIPTION III. OWNER'S CERTIFICATION

IV. INSPECTION 

AGENCY 

VERIFICATION

A

B X

STANDARD AIRW ORTHINESS CERTIFICATE (Indicate cate gory)

SPECIAL AIR W ORTHINESS CERTIFICATE (Check appropriate item s)

1. REGISTR ATION M ARK

 N 51CA

APPLICAT ION IS H EREBY M A DE FOR: (Check applicabl e item s)

2. AIRCRAFT BU ILDER'S NAME (M ake)

 C essna

3. AIRCRAFT M ODEL DE SIGNATION FAA CODING

 551

4. YR. MFR.

 19 92

7. ENGINE M ODEL DE SIGNATION

 JT 15D-4

10. PRO PELLER MODEL DESIG NATION

 N/A IMPORT

11. AIRC RAFT IS (Check if appl icable)

DATE DISTRICT OFFICE DESIGNEE'S SIG NATURE AND NO. FAA INSPECTOR 'S SIGNATURE

 (Check ALL appli cable bloc ks in item s A and B)

A. I fin d th at t he a ircr aft desc ribe d in Sec tion I o r VI I me ets requ irem ents for

X

NAME

Cessna A ircraft Company

ADDRESS 

W ichi ta, Kansas 67277-7 704

B. AIRCRA FT CE RTIFICATIO N BAS IS (C heck appli cable bloc ks and com plete items as indic ated)

X

C. AIRCRAFT OPERATION A ND M AINTENANCE RECORDS

CHECK IF RECORDS IN

 COMPLIANCE W ITH 

14 CF R se ctio n 91 .417

TOTAL AIRFRAM E HOURS

2509 3

DATE OF APPLI CATION

11/25/96

D. CERTIFICATION - I hereby certify that I am the regi ster ed owner (or his age nt) of the aircr aft desc ribed ab ove, tha t the ai rcraft i s registered with the Federa l Av iati on A dmin istr atio n in acc ordance with

Title 49 of the U nited Sta tes Co de 44101 et seq . and appli cabl e Fe dera l Av iati on R egul ations, and that the air craft ha s be en i nspected and is airw orthy and el igible for the airworthi ness cer tifi cate

requested.

A. THE AIRCRAFT DES CRIBED ABOVE HAS B EEN IN SPECTE D AND FOUND AIRW OR THY BY : (Com plete this section only if 14 CFR p art 21 .183( d) applies).

NAM E AND T ITLE (Prin t or type)

A.D. Smith, Quality Contr ol M anager

SIGNATURE

DATE TITLE SIGNATURE

IN STR UC TION S - Print or type. Do not w rite in shaded areas; these are for FAA

use only. Subm it original only to an authorized FAA Representative. If additional

space is required, use attachm ent. For special flight perm its com plete Sections

II, VI, and VII as applicable.

B. Inspecti on for a special fli ght perm it u nder Sec tion VII

 wa s c ond ucted by:

6. ENGINE BUILDER 'S NAM E (Make)

 UACL

9. PROP ELLER B UILDER' S NAME (Make)

 N/A

5. AIRCR AFT SER IAL NO.

 55 1-0004

8. NUMBER OF ENGINES

 Two

IF DEALER, CHECK HERE

AIRCRAFT LISTING (Gi ve page numb er(s))

N/A

SUPPLEMENTAL TYPE CERTIFICAT E (Li st number of each ST C inc orpor ated)

N/A

AIRCRAFT M ANUFA CTURER (Give name or firm) 

U.S. D epa rtment

of Tr ansportation

Federal Aviation

Administration

Certificate No.)

O.M .B. N o. 2120-0018

NORMAL UTILITY ACROBATIC TRANSPORT COM MUTER BALLOON

FAA Form 8130-6 (5-01) Supersedes Previous Edition NSN: 0052-00-024-7006

C MULTIPLE AIR W ORTHINESS CERTIFICATE (Check ABOVE " Restr icted Oper ation " and "Standard " or "Limi ted" as ap plicable.)

SPECIAL FLIGHT PERM IT (Indi cate 

oper ati on to be conduc ted, t hen

 com plete S ecti on V I or VII as 

applicable on rev erse side)

LIMITED

PROVIS IONAL (Indicate class)

RESTRICTED (Indi cate operation( s) to

 be c onducted)

AGRICULTURE AN D PEST CONTROL

FOREST (W ildlife c onservation)

CLAS S I

CLAS S II

AERIAL

PATRO LLING

 AERIAL ADVER TISING

 WEATHER CONTROL

AM ATEUR BUILT

CREW TRAINING

EXHIBITION

MARKET SURVEY

DELIVERIN G OR EX PORTING

TO SHOW COM PLIAN CE W ITH THE CFR

CUSTOM ER DEMONSTRATION FLIGHTS

PRODUCTION FLIGHT TESTING

FERRY FLIGHT FOR R EPAIRS, A LTERATION S, MAINT ENANCE, O R STORAGE

EVACUATE FROM AREA OF IM PE NDING DANGER

OPERATION IN EX CESS OF M AX IMUM CERTIF ICATED TAKE -OFF W EIGHT

RESEARCH AND DEVELOPMENT

AIR RACING

X

EXPERIM ENTAL (Indica te operati on(s)

 to be c onducted) X

OTHER (Specify)

OPERATING (Prim ary Category) KIT BUILT AIRCRAFT 

PRIM ARY

FAA INSPECTOR

14 CFR par t 65

FAA DE SIGNEE

14 CFR part 121 OR 135 14 CFR pa rt 145

THE CERTIFICA TE REQUESTED

AM ENDM ENT OR MODIFICATION OF CURRENT AIRW ORTHINESS CERTIFICATE

CERTIFICATE HOLDER UNDER

1 OTHER

4 1

3 6

4

2

5

3

4

 8

3

6

3

2

5

1

2

4

1

0

1

4

0

7

6

4

3

2

1

5

7

2

5

6

5

2
11/06/01 AC 21-12B

Appendix 1

Page 13

FIGURE 13. SAMPLE FAA FORM 8130-6, APPLICATION FOR A PRIMARY CATEGORY

CERTIFICATE – AIRCRAFT CERTIFICATED UNDER SECTION 21.191(h)

(FACE SIDE ONLY)

APPLICATION FOR

AIRW ORTHINESS

CERTIFICATE

II. CERTIFICATION REQUESTED

EXPERIMEN TAL ONLY (Enter hours flown s ince last certificate

CERTIFICATED MECHANIC (Give CERTIFICATED R EPAIR STATION (Give Certificate

AIRCRAFT SPECIFICATION O R TYPE CER TIFICATE D ATA SHEET (Give No. and AIRW ORTHINES S DIRECTIVES (Check if all applicable A D's c ompli ed wi th and giv e the number of

the l ast A D SUP PLEME NT av ailable in the biweekly s eries as of the date of applic ation) 

96- 23

issued or renewed)

0.0

 No.)

Revision No.)

A1W 1

 14 CF R part 121 C ERTIFICATE H OLDER (Give Certificate No.)

A. REGISTE RED OW NER (A s show n on c ertifi cate of airc raft r egistr ation)

V. FAA 

REPRESENTATIVE 

CERTIFICATION

I. AIRCRAFT

DESCRIPTION III. OWNER'S CERTIFICATION

IV. INSPECTION 

AGENCY 

VERIFICATION

A

B X

STANDARD AIRW ORTHINESS CERTIFICATE (Indicate category)

SPECIAL AIR W ORTHINESS CERTIFICATE (Check appropriate items)

1. REGISTR ATION MARK

 N654GL

APPLICAT ION IS H EREBY MA DE FOR: (Check applicabl e items)

2. AIRCRAFT BU ILDER'S NAME (Make)

 N ight

3. AIRCRAFT MODEL DE SIGNATION FAA CODING

 N7-xray

4. YR. MFR.

 1996

7. ENGINE MODEL DE SIGNATION

 10-360-ES

10. PRO PELLER MODEL DESIG NATION

 2A 34C 209 IMPORT

11. AIRC RAFT IS (Check if appl icable)

DATE DISTRICT OFFICE DESIGNEE'S SIG NATURE AND NO. FAA INSPECTOR 'S SIGNATURE

 (Check ALL appli cable bloc ks in item s A and B)

A. I find that the aircr aft desc ribed in Sec tion I or VII meets requirements for

X X

NAME

Mary Test

ADDRESS 

78 China Drive

Jumpi ng, Texas 89765

B. AIRCRA FT CE RTIFICATIO N BAS IS (C heck appli cable bloc ks and complete items as indic ated)

X

C. AIRCRAFT OPERATION A ND MAINTENANCE RECORDS

CHECK IF RECORDS IN

 COMPLIANCE W ITH 

14 CF R section 91.417

TOTAL AIRFRAME HOURS

2.2 3

DATE OF APPLICATION

11/25/96

D. CERTIFICATION - I hereby certify that I am the regi ster ed owner (or his agent) of the aircr aft desc ribed above, that the ai rcraft i s registered with the Federal Av iati on A dministr ation in acc ordance with

Title 49 of the U nited States Code 44101 et seq. and appli cabl e Federal Av iati on R egul ations, and that the air craft has been i nspected and is airw orthy and el igible for the airworthi ness cer tifi cate

requested.

A. THE AIRCRAFT DES CRIBED ABOVE HAS B EEN IN SPECTE D AND FOUND AIRW OR THY BY : (Complete this section only if 14 CFR part 21 .183( d) applies).

NAME AND T ITLE (Print or type)

Mary Tes t, Owner

SIGNATURE

DATE TITLE SIGNATURE

INSTRUCTIONS - Print or type. Do not write in shaded areas; these are for FAA

use only. Subm it original only to an authorized FAA Representative. If additional

space is required, use attachm ent. For special flight perm its com plete Sections

II, VI, and VII as applicable.

B. Inspecti on for a special fli ght permit under Sec tion VII

 was c onducted by:

6. ENGINE BUILDER 'S NAME (Make)

 TCM

9. PROP ELLER B UILDER' S NAME (Make)

 Mc Cauley

5. AIRCR AFT SER IAL NO.

 NX09

8. NUMBER OF ENGINES

 One

IF DEALER, CHECK HERE

AIRCRAFT LISTING (Gi ve page number(s))

N/A

SUPPLEMENTAL TYPE CERTIFICAT E (Li st number of each ST C inc orpor ated)

N/A

AIRCRAFT MANUFA CTURER (Give name or firm) 

U.S. D epartment

of Tr ansportation

Federal Aviation

Administration

Certificate No.)

O.M .B. No. 2120-0018

NORMAL UTILITY ACROBATIC TRANSPORT COMMUTER BALLOON

FAA Form 8130-6 (5-01) Supersedes Previous Edition NSN: 0052-00-024-7006

C MULTIPLE AIR W ORTHINESS CERTIFICATE (Check ABOVE " Restr icted Oper ation" and "Standard" or "Limi ted" as applicable.)

SPECIAL FLIGHT PERMIT (Indi cate 

oper ati on to be conduc ted, then

 complete S ecti on V I or VII as 

applicable on rev erse side)

LIMITED

PROVIS IONAL (Indicate class)

RESTRICTED (Indi cate operation( s) to

 be c onducted)

AGRICULTURE AN D PEST CONTROL

FOREST (W ildlife c onservation)

CLAS S I

CLAS S II

AERIAL

PATRO LLING

 AERIAL ADVER TISING

 WEATHER CONTROL

AMATEUR BUILT

CREW TRAINING

EXHIBITION

MARKET SURVEY

DELIVERIN G OR EX PORTING

TO SHOW COMPLIAN CE W ITH THE CFR

CUSTOMER DEMONSTRATION FLIGHTS

PRODUCTION FLIGHT TESTING

FERRY FLIGHT FOR R EPAIRS, A LTERATION S, MAINT ENANCE, O R STORAGE

EVACUATE FROM AREA OF IMPE NDING DANGER

OPERATION IN EX CESS OF MAX IMUM CERTIF ICATED TAKE -OFF W EIGHT

RESEARCH AND DEVELOPMENT

AIR RACING EXPERIM ENTAL (Indicate operati on(s)

 to be c onducted) X

OTHER (Specify)

X OPERATING (Primary Category) KIT BUILT AIRCRAFT 

PRIMARY

FAA INSPECTOR

14 CFR par t 65

FAA DE SIGNEE

14 CFR part 121 OR 135 14 CFR part 145

THE CERTIFICA TE REQUESTED

AMENDMENT OR MODIFICATION OF CURRENT AIRW ORTHINESS CERTIFICATE

CERTIFICATE HOLDER UNDER

1 OTHER

4 1

3 6

4

2

5

3

4

 8

3

6

3

2

5

1

2

4

1

0

1

4

0

7

6

4

3

2

1

5

7

2

5

6

5

2
AC 21-12B 11/06/01

Appendix 1

Page 14

FIGURE 14. SAMPLE FAA FORM 8130-6, APPLICATION FOR A SPECIAL

AIRWORTHINESS CERTIFICATE – SPECIAL FLIGHT PERMIT FOR FERRY FLIGHT IN

EXCESS OF MAXIMUM TAKE-OFF WEIGHT

(FACE SIDE)

APPLICATION FOR

AIR W OR TH IN ESS

CERTIFICATE

II. CERTIFICATION REQUESTED

EXPERIM EN TAL ONLY (Enter hours flown s ince last certificate

CERTIFICATED M ECHANIC (Give CERTIFICATED R EPAIR STATION (Give Certificate

AIRCRAFT SPECI FICATION O R TYPE CER TIFICATE D ATA SHEET (Give No. and AIRW ORTHINES S DIRECTIVES (Check if all applicable A D's c om pli ed wi th and giv e the num ber of

the last AD SUPP LEM EN T availabl e in the biweek ly series as of the date of application)

issued or renewed)

 No.)

Revision No.)

 14 CF R part 121 C ERTIFICATE H OLDER (Give

Certificate No.)

A. REGISTE RED OW NER (A s show n on c ertifi cate of airc raft r egistr ation)

V. FAA 

REPRESENTATIVE 

CERTIFICATION

I. AIRCRAFT

DESCRIPTION III. OWNER'S CERTIFICATION

IV. INSPECTION 

AGENCY 

VERIFICATION

A

B X

STANDARD AIRW ORTHINESS CERTIFICATE (Ind icate cate gory)

SPECIAL AIR W ORTHINESS CERTIFICATE (Check appropriate item s)

1. REGISTR ATION M ARK

 

APPLICAT ION IS H EREBY M A DE FOR: (Check applicabl e item s)

2. AIRCRAFT BU ILDER'S NAM E (M ake) 3. AIRCRAFT M ODEL DE SIGNATION 4. YR. M FR. FAA CODING

7. ENGINE M ODEL DE SIGNATION

10. PRO PELLER M ODEL DESIG NATION

IM PORT

11. AIRC RAFT IS (Check if appl icable)

DATE DISTRICT OFFICE DESIGNEE'S SIG NATURE AND NO. FAA INSPECTOR 'S SIGNATURE

 (Check ALL appli cable bloc ks in item s A and B)

A. I find that the aircr aft desc ribed in Sec tion I or VII meets requirem ents for

NAME ADDRESS

B. AIRCRA FT CE RTIFI CATIO N BAS IS (C heck appli cable bloc ks and com plete item s as indic ated)

C. AIRCRAFT OPERATION A ND M AINTENANCE RECORDS

CHECK IF RECORDS IN

 COM PLIANCE W ITH 

14 CF R section 91.417

TOTAL AIRFRAM E HOURS

3

DATE OF APPLI CATION

D. CERTIFICATION - I hereby certify that I am the regi ster ed owner (or his agent) of the aircr aft desc ribed above, that the ai rcraft i s registered with the Federal Av iati on A dministr ation in acc ordance with

Title 49 of the U nited States Code 44101 et se q . and appli cabl e Federal Av iati on R egul ations, and that the air craft has been i nspected and is airw orthy and el igible for the a irworthi ness cer tifi cate

requested.

A. THE AIRCRAFT DES CRIBED ABOVE HAS B EEN IN SPECTE D AND FOUND AIRW OR THY BY : (Com plete this sectio n only if 14 CFR p art 21 .183( d) applies).

NAM E AND T ITLE (Prin t or type) SIGNATURE

DATE TITLE SIGNATURE

INSTRUCTIONS - Print or type. D o not w rite in shaded areas; these are for F AA

use only. Subm it original only to an authorized F AA R epresentative. If additional

space is required, use attachm ent. F or special flight perm its com plete Sections

II, VI, and VII as applicable.

B. Inspecti on for a special fli ght perm it under Sec tion VII

 was c onducted by:

6. ENGINE BUILDER 'S NAM E (M ake)

9. PROP ELLER B UILDER' S NAM E (M ake)

5. AIRCR AFT SER IAL NO.

8. NUM BER OF ENGINES

IF DEALER, CHECK HERE

AIRCRAFT LISTI NG (Gi ve pag e numb er(s)) SUPPLEM ENTAL TYPE CERTI FICAT E (Li st nu mber of ea ch ST C inc orpor ated)

AIRCRAFT M ANUFA CTURER (Give n ame or firm) 

U.S. D epartm ent

of Tr ansportation

Federal Aviation

Administration

Certificate No.)

O.M .B. N o. 2120-0018

NORMAL UTILITY ACROBATIC TRANSPORT COMMUTER BALLOON

FAA Form 8130-6 (5-01) Supersedes Previous Edition NSN: 0052-00-024-7006

C M ULTIPLE AIR W ORTHINESS CERTIFICATE (Check ABOVE " Restr icted Oper ation" and "Standard" or "Lim i ted" as applicable.)

X

SPECIAL FLIGHT PERM IT (Indi cate 

oper ati on to be con duc ted , t hen

 com plete S ecti on V I or VII as 

applicable on rev erse side)

LIM ITED

PROVIS IONAL (Indicat e class)

RESTRICTED (Indi cate operation( s) to

 be c onducted)

AGRICULTURE AN D PEST CONTROL

FOREST (W ildlife c onservation)

CLAS S I

CLAS S II

AERIAL

PATRO LLING

 AERIAL ADVER TISING

 W EATHER CONTROL

AM ATEUR BUILT

CREW TRAINING

EXHIBITION

MARKET SURVEY

DELIVERIN G OR EX PORTING

TO SHOW COM PLIAN CE W ITH THE CFR

CUSTOM ER DEM ONSTRATION FLIGHTS

PRODUCTION FL IGHT TESTING

X

FERRY FLI GHT FOR R EPAIRS, A LTERATION S, M AINT ENANCE, O R STORAGE

EVACUATE FROM AREA OF IM PE NDING DANGER

OPERATION IN EX CESS OF M AX IM UM CERTIF ICATED TAKE -OFF W EIGHT

RESEARCH AND DEVELOPM ENT

AIR RACING EXPERIM ENTAL (Indicate operati on(s)

 to be c onducted)

OTHER (Specify)

OPERATING (Prim ary Category) KIT BUILT AIRCRAFT 

PRIM ARY

FAA INSPECTOR

14 CFR par t 65

FAA DE SIGNEE

14 CFR part 121 OR 135 14 CFR part 145

THE CERTIFICA TE REQUESTED

AM ENDM ENT OR M ODIFICATION OF CURRENT AIRW ORTHINESS CERTIFICATE

CERTIFICATE HOLDER UNDER

1 OTHER

4 1

3 6

4

2

5

3

4

 8

3

6

3

2

5

1

2

4

1

0

1

4

0

7

6

4

3

2

1

5

7

2

5

6

5

2
11/06/01 AC 21-12B

Appendix 1

Page 15

FIGURE 14. SAMPLE FAA FORM 8130-6, APPLICATION FOR A SPECIAL

AIRWORTHINESS CERTIFICATE – SPECIAL FLIGHT PERMIT FOR FERRY FLIGHT IN

EXCESS OF MAXIMUM TAKE-OFF WEIGHT

(REVERSE SIDE) (cont’d.)

PRODUCTION CERTIFICATE (Give produc tion c ertifi cate num ber)

TYPE CE RTIFICA TE ONLY

APPROVED PROD UCTION INSPE CTION SYSTEM

A. DESCRIPTION OF AIRCRAFT

VIII. AIRWORTHINESS

DOCUMENTATION

(FAA/DESIGNEE use only)

VI. PRODUCTIONFLIGHT TESTING

B. Current Ope rating Li mitati ons Attac hed

C. Data, Draw ings , Photographs, etc. (Attach when required)

D. Current W eight and B alance Infor mati on A vail able in Airc raft

E. M ajor Repair and A lter ation, F AA F orm 337 (Attach when required)

F. This inspection Rec orded in A ircraft Records

A. Operating Limi tati ons and M ark ings in Comp lian ce w ith 14 C FR s ecti on 9 1.9,

 as A ppl icable

H. Foreign Airwo rthine ss Cer tifica tion f or Imp ort Ai rcraft

 (Attac h when r equi red)

I. Previous A irwor thiness Certifi cate Issued in Accor dance with

J. Current Airwor thiness Certifi cate Issued in Accor dance with

G. Statement of Con for mit y, FAA Fo rm 813 0-9 (Attach when required)

SERIAL NUM BER

27- 647

DATE OF APPLI CATION SIGNATURE NAM E AND TITLE (Print or type)

NAME ADDRESS

A. MANUFACTURER

B. PRODUCTIO N BASIS (Check applicabl e item )

B. DESCRIPTION OF FLIGHT

FROM

El Pas o T exas

DEPARTURE DATE

11/30/96

TO

M aui, Hawaii

DATE

11/25/96

NAM E AND TITLE (Print or type)

Don Brow n, A gent

SIGNATURE

C. CREW REQUIRED TO OPERATE TH E AIRCRAFT AND ITS EQUIPM ENT

F. CERTIFICATION - I hereby certify that I am the r egis tered ow ner (or his agent) of the ai rcraft descr ibed above; that the air craft is registered with the Federal Avi ation Admini stration in 

accordance with Ti tle 49 of the U nited States Code 44101 et seq . and applicable Federal Aviation R egulations; and that the ai rcr aft has been inspected and is air wor thy for the fli ght

descr ibed.

VIA

San J ose, California

C. GIVE QUANTITY OF CERTI FICATES R EQUIRED F OR OPERAT ING NEEDS

BUILDER (M ake)

Piper

REGISTERED OW NER

W eldo n H. Jac kson

REGISTRATION M ARK

N4588P

MODEL

PA 23- 250

ADDRESS

P.O. Box 945, M aui, Hawaii 96782

DURATION

30 Days

D. THE AIRC RAFT DOES NOT M EET THE APPL ICABLE AI RW ORTHINE SS REQUIR EM ENTS AS FOLLOW S:

 Temporary Ferr y Fuel S tstem instal led in accor danc e wi th F AA F orm 337, "M ajor Repair and A lter ation" dated 12/88. 

 Gros s weight not to exceed 110% of c erti fied max imun wei ght.

E. THE FOLLOW ING RESTR ICTIONS A RE CONSID ERED NECE SSARY FOR SAFE OPE RATION: ( Use attachm ent if neces sary)

 1. W hen the air craft is in an overw eight condition, the des ign crui se s peed should not exceed 162 M PH.

 2. The fuel quanti ty should not exceed 140 gallons in the forward tank and 35 gal lons i n the aft tank.

 3. The sequence of use of the ferry tanks s hall be as s hown by a tempor ary plac ard installed in ful l vi ew of the pi lot.

CUSTOM ER DEM ONSTRATION FLIGHTS (Check if applicable)

X PILOT X CO-PILOT FLIGHT ENGINEER OTHER (Specify) 

14 CFR Section CAR (Original Attached)

14 CFR Section (Copy attached)

VII. SPECIAL FLIGHT PERMIT PURPOSES OTHER THAN PRODUCTION FLIGHT TEST

FAA Form 8130-6 (5-01) Supersedes Previous Edition NSN: 0052-00-024-7006
AC 21-12B 11/06/01

Appendix 1

Page 16

FIGURE 15. SAMPLE FAA FORM 8130-6, APPLICATION FOR A SPECIAL

AIRWORTHINESS CERTIFICATE – SPECIAL FLIGHT PERMIT FOR FERRY FLIGHT

(FACE SIDE)

APPLICATION FOR

AIRW ORTHINESS

CERTIFICATE

II. CERTIFICATION REQUESTED

EXPERIMEN TAL ONLY (Enter hours flown s ince last certificate

CERTIFICATED MECHANIC (Give CERTIFICATED R EPAIR STATION (Give Certificate

AIRCRAFT SPECIFICATION O R TYPE CER TIFICATE D ATA SHEET (Give No. and AIRW ORTHINES S DIRECTIVES (Check if all applicable A D's c ompli ed wi th and giv e the number of

the last AD SUPP LEMEN T availabl e in the biweek ly series as of the date of application)

issued or renewed)

N/A

 No.)

Revision No.)

 14 CF R part 121 C ERTIFICATE H OLDER (Give

Certificate No.)

A. REGISTE RED OW NER (A s show n on c ertifi cate of airc raft r egistr ation)

V. FAA 

REPRESENTATIVE 

CERTIFICATION

I. AIRCRAFT

DESCRIPTION III. OWNER'S CERTIFICATION

IV. INSPECTION 

AGENCY 

VERIFICATION

A

B X

STANDARD AIRW ORTHINESS CERTIFICATE (Indicate category)

SPECIAL AIR W ORTHINESS CERTIFICATE (Check appropriate items)

1. REGISTR ATION MARK

 

APPLICAT ION IS H EREBY MA DE FOR: (Check applicabl e items)

2. AIRCRAFT BU ILDER'S NAME (Make)

 

3. AIRCRAFT MODEL DE SIGNATION FAA CODING

 

4. YR. MFR.

 

7. ENGINE MODEL DE SIGNATION

 

10. PRO PELLER MODEL DESIG NATION

 IMPORT

11. AIRC RAFT IS (Check if appl icable)

DATE DISTRICT OFFICE DESIGNEE'S SIG NATURE AND NO. FAA INSPECTOR 'S SIGNATURE

 (Check ALL appli cable bloc ks in item s A and B)

A. I find that the aircr aft desc ribed in Sec tion I or VII meets requirements for

NAME ADDRESS 

B. AIRCRA FT CE RTIFICATIO N BAS IS (C heck appli cable bloc ks and complete items as indic ated)

C. AIRCRAFT OPERATION A ND MAINTENANCE RECORDS

CHECK IF RECORDS IN

 COMPLIANCE W ITH 

14 CF R section 91.417

TOTAL AIRFRAME HOURS

3

DATE OF APPLICATION

D. CERTIFICATION - I hereby certify that I am the regi ster ed owner (or his agent) of the aircr aft desc ribed above, that the ai rcraft i s registered with the Federal Av iati on A dministr ation in acc ordance with

Title 49 of the U nited States Code 44101 et seq. and appli cabl e Federal Av iati on R egul ations, and that the air craft has been i nspected and is airw orthy and el igible for the airworthi ness cer tifi cate

requested.

A. THE AIRCRAFT DES CRIBED ABOVE HAS B EEN IN SPECTED AND FOUND AIRW OR THY BY : (Complete this section only if 14 CFR part 21 .183( d) applies).

NAME AND T ITLE (Print or type) SIGNATURE

DATE TITLE SIGNATURE

INSTRUCTIONS - Print or type. Do not write in shaded areas; these are for FAA

use only. Subm it original only to an authorized FAA Representative. If additional

space is required, use attachm ent. For special flight perm its com plete Sections

II, VI, and VII as applicable.

B. Inspecti on for a special fli ght permit under Sec tion VII

 was c onducted by:

6. ENGINE BUILDER 'S NAME (Make)

 

9. PROP ELLER B UILDER' S NAME (Make)

 

5. AIRCR AFT SER IAL NO.

 

8. NUMBER OF ENGINES

 

IF DEALER, CHECK HERE

AIRCRAFT LISTING (Gi ve page number(s)) SUPPLEMENTAL TYPE CERTIFICAT E (Li st number of each ST C inc orpor ated)

AIRCRAFT MANUFA CTURER (Give name or firm) 

U.S. D epartment

of Tr ansportation

Federal Aviation

Administration

Certificate No.)

O.M .B. No. 2120-0018

NORMAL UTILITY ACROBATIC TRANSPORT COMMUTER BALLOON

FAA Form 8130-6 (5-01) Supersedes Previous Edition NSN: 0052-00-024-7006

C MULTIPLE AIR W ORTHINESS CERTIFICATE (Check ABOVE " Restr icted Oper ation" and "Standard" or "Limi ted" as applicable.)

X

SPECIAL FLIGHT PERMIT (Indi cate 

oper ati on to be conduc ted, then

 complete S ecti on V I or VII as 

applicable on rev erse side)

LIMITED

PROVIS IONAL (Indicate class)

RESTRICTED (Indi cate operation( s) to

 be c onducted)

AGRICULTURE AN D PEST CONTROL

FOREST (W ildlife c onservation)

CLAS S I

CLAS S II

AERIAL

PATRO LLING

 AERIAL ADVER TISING

 WEATHER CONTROL

AMATEUR BUILT

CREW TRAINING

EXHIBITION

MARKET SURVEY

DELIVERIN G OR EX PORTING

TO SHOW COMPLIAN CE W ITH THE CFR

CUSTOMER DEMONSTRATION FLIGHTS

PRODUCTION FLIGHT TESTING

X FERRY FLIGHT FOR R EPAIRS, A LTERATION S, MAINT ENANCE, O R STORAGE

EVACUATE FROM AREA OF IMPE NDING DANGER

OPERATION IN EX CESS OF MAX IMUM CERTIF ICATED TAKE -OFF W EIGHT

RESEARCH AND DEVELOPMENT

EXPERIM ENTAL (Indicate operati on(s) AIR RACING to be c onducted)

OTHER (Specify)

OPERATING (Primary Category) KIT BUILT AIRCRAFT 

PRIMARY

FAA INSPECTOR

14 CFR par t 65

FAA DE SIGNEE

14 CFR part 121 OR 135 14 CFR part 145

THE CERTIFICA TE REQUESTED

AMENDMENT OR MODIFICATION OF CURRENT AIRW ORTHINESS CERTIFICATE

CERTIFICATE HOLDER UNDER

1 OTHER

4 1

3 6

4

2

5

3

4

 8

3

6

3

2

5

1

2

4

1

0

1

4

0

7

6

4

3

2

1

5

7

2

5

6

5

2
11/06/01 AC 21-12B

Appendix 1

Page 17

FIGURE 15. SAMPLE FAA FORM 8130-6, APPLICATION FOR A SPECIAL

AIRWORTHINESS CERTIFICATE – SPECIAL FLIGHT PERMIT FOR FERRY FLIGHT

(REVERSE SIDE) (cont’d.)

PRODUCTION CERTIFICATE (Give produc tion c ertifi cate num ber)

TYPE CE RTIFICA TE ONLY

APPROVED PROD UCTION INSPE CTION SYSTEM

A. DESCRIPTION OF AIRCRAFT

VIII. AIRWORTHINESS

DOCUMENTATION

(FAA/DESIGNEE use only)

VI. PRODUCTIONFLIGHT TESTING

B. Current Operat ing Li mitati ons Attac hed

C. Data, Draw ings , Photographs, etc. (Attach when requ ired)

D. Current W eight and B alan ce I nfor mati on A vail able in Airc raft

E. Major Repa ir a nd A lter atio n, F AA F orm 337 (Attach when required)

F. This inspection Rec orded in A ircra ft Records

A. Operating Limi tati ons and Mark ings in Compliance w ith 14 C FR s ecti on 91.9,

 as A ppl ica ble

H. Foreign Airworthiness Cer tification f or Import Ai rcraft

 (Attac h when r equi red)

I. Previous A irwor thiness Certifi cate Issue d in Accor dance with

J. Current Airwor thiness Ce rtifi cate Issued in Accor dance with

G. Statement of Con for mity, FAA Form 8130-9 (Attach when requ ired)

SERIAL NUMBER

4099

DATE OF APPLICATION SIGNATURE NAM E AND TITLE (Print or type)

NAME ADDRESS

A. MANUFACTURER

B. PRODUCTIO N BASIS (Check applicabl e item)

B. DESCRIPTION OF FLIGHT

FROM

W aterl oo, Iowa

DEPARTURE DATE

11/30/96

TO

Des M oines, Iowa

DATE

11/25/96

NAME AND TITLE (Print or type)

Robert F . Tur ner, Owner SIGNATURE

X

C. CREW REQUIRED TO OPERATE TH E AIRCRAFT AND ITS EQUIPM ENT

F. CERTIFICATION - I hereby certify that I am the r egis tered ow ner (or his agent) of the ai rcraft descr ibed above; that the air craft is registered with the Federal Avi ation Admini stra tion in 

accordance with Ti tle 49 of the U nited Sta tes Co de 44101 et seq . and applicable Federal Aviation R egulations; and that the ai rcr aft ha s been inspecte d a nd is air wor thy for the fli ght

descr ibed.

VIA

Direct

C. GIVE QUANTITY OF CERTIFICATES R EQUIRED F OR OPERAT ING NEEDS

BUILDER (Make)

Bellancia

REGISTERED OW NER

Robert F. T urner

REGISTRATION MARK

N254B

MODEL

14-19-2

ADDRESS 

4623 Mountainview Dri ve, W ate rloo , Iowa 5 0701

DURATION

12/0 3/96

D. THE AIRC RAFT DOES NOT M EET THE APPLICABLE AI RW ORTHINE SS REQUIR EMENTS AS FOLLOW S:

Aircraft damag ed i n landin g ac cide nt. Tem porary r epai rs have been mad e fo r on e fl ight to repair s hop at D es M oines - Dodge Ai rpor t, w here per manent r epai rs w ill be made.

E. THE FOLLOW ING RESTR ICTIONS A RE CONSID ERED NECE SSARY FOR SAFE OPE RATION: ( Use atta chm ent if neces sary)

1. Airspeed sh oul d not exc eed 11 5 M PH.

2. Land ing gear should no t be r etr act ed.

3. N o passengers or carg o sh ould be carr ied.

CUSTOM ER DEM ONSTRATION FLIGHTS (Check if a pplicable)

PILOT CO-PILOT FLIGHT ENGINEER OTHER (Specify) 

14 CFR Section CAR (Original Attached)

14 CFR Section (Copy attached)

VII. SPECIAL FLIGHT PERMIT PURPOSES OTHER THAN PRODUCTION FLIGHT TEST

FAA Form 8130-6 (5-01) Supersedes Previous Edition NSN: 0052-00-024-7006
AC 21-12B 11/06/01

Appendix 1

Page 18

FIGURE 16. SAMPLE FAA FORM 8130-6, APPLICATION FOR A SPECIAL

AIRWORTHINESS CERTIFICATE – SPECIAL FLIGHT PERMIT FOR PRODUCTION

FLIGHT TESTING (FACE SIDE)

APPLICATION FOR

AIR W OR TH IN ESS

CERTIFICATE

II. CERTIFICATION REQUESTED

EXPERIM EN TAL ONLY (Enter hours flown s ince last certificate

CERTIFICATED M ECHANIC (Give CERTIFICATED R EPAIR STATION (Give Certificate

AIRCRAFT SPECI FICATION O R TYPE CER TIFICATE D ATA SHEET (Give No. and AIRW ORTHINES S DIRECTIVES (Check if all applicable A D's c om pli ed wi th and giv e the num ber of

the last AD SUPP LEM EN T availabl e in the biweek ly series as of the date of application)

issued or renewed)

 No.)

Revision No.)

 14 CF R part 121 C ERTIFICATE H OLDER (Give

Certificate No.)

A. REGISTE RED OW NER (A s show n on c ertifi cate of airc raft r egistr ation)

V. FAA 

REPRESENTATIVE 

CERTIFICATION

I. AIRCRAFT

DESCRIPTION III. OWNER'S CERTIFICATION

IV. INSPECTION 

AGENCY 

VERIFICATION

A

B X

STANDARD AIRW ORTHINESS CERTIFICATE (Ind icate cate gory)

SPECIAL AIR W ORTHINESS CERTIFICATE (Check appropriate item s)

1. REGISTR ATION M ARK

APPLICAT ION IS H EREBY M A DE FOR: (Check applicabl e item s)

2. AIRCRAFT BU ILDER'S NAM E (M ake) 3. AIRCRAFT M ODEL DE SIGNATION 4. YR. M FR. FAA CODING

7. ENGINE M ODEL DE SIGNATION

10. PRO PELLER M ODEL DESIG NATION

IM PORT

11. AIRC RAFT IS (Check if appl icable)

DATE DISTRICT OFFICE DESIGNEE'S SIG NATURE AND NO. FAA INSPECTOR 'S SIGNATURE

 (Check ALL appli cable bloc ks in item s A and B)

A. I find that the aircr aft desc ribed in Sec tion I or VII meets requirem ents for

NAME ADDRESS

B. AIRCRA FT CE RTIFI CATIO N BAS IS (C heck appli cable bloc ks and com plete item s as indic ated)

C. AIRCRAFT OPERATION A ND M AINTENANCE RECORDS

CHECK IF RECORDS IN

 COM PLIANCE W ITH 

14 CF R section 91.417

TOTAL AIRFRAM E HOURS

3

DATE OF APPLI CATION

D. CERTIFICATION - I hereby certify that I am the regi ster ed owner (or his agent) of the aircr aft desc ribed above, that the ai rcraft i s registered with the Federal Av iati on A dministr ation in acc ordance with

Title 49 of the U nited States Code 44101 et se q . and appli cabl e Federal Av iati on R egul ations, and that the air craft has been i nspected and is airw orthy and el igible for the a irworthi ness cer tifi cate

requested.

A. THE AIRCRAFT DES CRIBED ABOVE HAS B EEN IN SPECTE D AND FOUND AIRW OR THY BY : (Com plete this sectio n only if 14 CFR p art 21 .183( d) applies).

NAM E AND T ITLE (Prin t or type) SIGNATURE

DATE TITLE SIGNATURE

INSTRUCTIONS - Print or type. D o not w rite in shaded areas; these are for F AA

use only. Subm it original only to an authorized F AA R epresentative. If additional

space is required, use attachm ent. F or special flight perm its com plete Sections

II, VI, and VII as applicable.

B. Inspecti on for a special fli ght perm it under Sec tion VII

 was c onducted by:

6. ENGINE BUILDER 'S NAM E (M ake)

9. PROP ELLER B UILDER' S NAM E (M ake)

5. AIRCR AFT SER IAL NO.

8. NUM BER OF ENGINES

IF DEALER, CHECK HERE

AIRCRAFT LISTI NG (Gi ve pag e numb er(s)) SUPPLEM ENTAL TYPE CERTI FICAT E (Li st nu mber of ea ch ST C inc orpor ated)

AIRCRAFT M ANUFA CTURER (Give n ame or firm) 

U.S. D epartm ent

of Tr ansportation

Federal Aviation

Administration

Certificate No.)

O.M .B. N o. 2120-0018

NORMAL UTILITY ACROBATIC TRANSPORT COMMUTER BALLOON

FAA Form 8130-6 (5-01) Supersedes Previous Edition NSN: 0052-00-024-7006 

C M ULTIPLE AIR W ORTHINESS CERTIFICATE (Check ABOVE " Restr icted Oper ation" and "Standard" or "Lim i ted" as applicable.)

x

SPECIAL FLIGHT PERM IT (Indi cate 

oper ati on to be con duc ted , t hen

 com plete S ecti on V I or VII as 

applicable on rev erse side)

LIM ITED

PROVIS IONAL (Indicat e class)

RESTRICTED (Indi cate operation( s) to

 be c onducted)

AGRICULTURE AN D PEST CONTROL

FOREST (W ildlife c onservation)

CLAS S I

CLAS S II

AERIAL

PATRO LLING

 AERIAL ADVER TISING

 W EATHER CONTROL

AM ATEUR BUILT

CREW TRAINING

EXHIBITION

MARKET SURVEY

DELIVERIN G OR EX PORTING

TO SHOW COM PLIAN CE W ITH THE CFR

CUSTOM ER DEM ONSTRATION FLIGHTS

PRODUCTION FL IGHT TESTING

FERRY FLI GHT FOR R EPAIRS, A LTERATION S, M AINT ENANCE, O R STORAGE

EVACUATE FROM AREA OF IM PE NDING DANGER

OPERATION IN EX CESS OF M AX IM UM CERTIF ICATED TAKE -OFF W EIGHT

RESEARCH AND DEVELOPM ENT

EXPERIM ENTAL (Indicate operati on(s) AIR RACING to be c onducted)

x

OTHER (Specify)

OPERATING (Prim ary Category) KIT BUILT AIRCRAFT 

PRIM ARY

FAA INSPECTOR

14 CFR par t 65

FAA DE SIGNEE

14 CFR part 121 OR 135 14 CFR part 145

THE CERTIFICA TE REQUESTED

AM ENDM ENT OR M ODIFICATION OF CURRENT AIRW ORTHINESS CERTIFICATE

CERTIFICATE HOLDER UNDER

1 OTHER

4 1

3 6

4

2

5

3

4

 8

3

6

3

2

5

1

2

4

1

0

1

4

0

7

6

4

3

2

1

5

7

2

5

6

6

5

2
11/06/01 AC 21-12B

Appendix 1

Page 19

FIGURE 16. SAMPLE FAA FORM 8130-6, APPLICATION FOR A SPECIAL

AIRWORTHINESS CERTIFICATE – SPECIAL FLIGHT PERMIT FOR PRODUCTION

FLIGHT TESTING (REVERSE SIDE) (cont’d.)

PRODUCTION CERTIFICATE (Give produc tion c ertifi cate number) P C# 700

TYPE CERTIFICATE ONLY

APPROVED PROD UCTION INSPE CTION SYSTEM

A. DESCRIPTION OF AIRCRAFT

VIII. AIRWORTHINESS

DOCUMENTATION

(FAA/DESIGNEE use only)

VI. PRODUCTIONFLIGHT TESTING

B. Current Operat ing Li mitati ons Attac hed

C. Data, Draw ings , Photographs, etc. (Attach when requ ired)

D. Current W eight and Balan ce I nfor mati on A vail able in Airc raft

E. Major Repa ir a nd A lter atio n, F AA F orm 337 (Attach when required)

F. This inspection Rec orded in A ircra ft Records

A. Operating Limi tati ons and Mark ings in Compliance w ith 14 C FR s ecti on 91.9,

 as Appl ica ble

H. Foreign Airworthiness Cer tification f or Import Ai rcraft

 (Attac h when r equi red)

I. Previous A irwor thiness Certifi cate Issue d in Accor dance with

J. Current Airwor thiness Ce rtifi cate Issued in Accor dance with

G. Statement of Con for mity, FAA Form 8130-9 (Attach when requ ired)

SERIAL NUMBER

DATE OF APPLICATION SIGNATURE

11/25/96

NAME AND TITLE (Print or type)

John C. Burn s, P resi dent

NAME

ABC Airc raft C ompany

ADDRESS

509 More land Blv d, P aloma New Yo rk 2 0101

A. MANUFACTURER

B. PRODUCTIO N BASIS (Check applicabl e item)

B. DESCRIPTION OF FLIGHT

FROM

DEPARTURE DATE

TO

DATE NAME AND TITLE (Print or type) SIGNATURE

C. CREW REQUIRED TO OPERATE TH E AIRCRAFT AND ITS EQUIPMENT

F. CERTIFICATION - I hereby certify that I am the r egis tered ow ner (or his agent) of the ai rcraft descr ibed above; that the air craft is registered with the Federal Avi ation Admini stra tion in 

accordance with Ti tle 49 of the U nited Sta tes Co de 44101 et seq . and applicable Federal Aviation R egulations; and that the ai rcr aft ha s been inspecte d a nd is air wor thy for the fli ght

descr ibed.

VIA

C. GIVE QUANTITY OF CERTIFICATES R EQUIRED F OR OPERAT ING NEEDS

BUILDER (Make)

REGISTERED OW NER

REGISTRATION MARK

MODEL

ADDRESS

DURATION

D. THE AIRC RAFT DOES NOT MEET THE APPLICABLE AI RW ORTHINESS REQUIR EMENTS AS FOLLOW S:

E. THE FOLLOW ING RESTR ICTIONS ARE CONSID ERED NECESSARY FOR SAFE OPE RATION: ( Use atta chment if neces sary)

CUSTOMER DEMONSTRATION FLIGHTS (Check if a pplicable)

PILOT CO-PILOT FLIGHT ENGINEER OTHER (Specify) 

14 CFR Section CAR (Original Attached)

14 CFR Section (Copy attached)

VII. SPECIAL FLIGHT PERMIT PURPOSES OTHER THAN PRODUCTION FLIGHT TEST

X

FAA Form 8130-6 (5-01) Supersedes Previous Edition NSN: 0052-00-024-7006
AC 21-12B 11/06/01

Appendix 1

Page 20

FIGURE 17. SAMPLE FAA FORM 8130-6, APPLICATION FOR A MULTIPLE

AIRWORTHINESS CERTIFICATE

(FACE SIDE ONLY)

APPLICATION FOR

AIRW ORTHINESS

CERTIFICATE

II. CERTIFICATION REQUESTED

EXPERIMEN TAL ONLY (Enter hours flown s ince last certificate

CERTIFICATED MECHANIC (Give CERTIFICATED R EPAIR STATION (Give Certificate

AIRCRAFT SPECIFICATION O R TYPE CER TIFICATE D ATA SHEET (Give No. and AIRW ORTHINES S DIRECTIVES (Check if all applicable A D's c ompli ed wi th and giv e the number of

the las t AD SUPPLEMENT avai lable in the bi weekl y ser ies as of the date of application) 

96- 23

issued or renewed)

N/A

 No.)

Revision No.)

1A2 R ev. 33, AR- 7 Rev. 9

 14 CF R part 121 C ERTIFICATE H OLDER (Give

Certificate No.)

A. REGISTE RED OW NER (A s show n on c ertifi cate of airc raft r egistr ation)

V. FAA 

REPRESENTATIVE 

CERTIFICATION

I. AIRCRAFT

DESCRIPTION III. OWNER'S CERTIFICATION

IV. INSPECTION 

AGENCY 

VERIFICATION

A

B

X STANDARD AIRW ORTHINESS CERTIFICATE (Indicate category)

SPECIAL AIR W ORTHINESS CERTIFICATE (Check appropriate items)

1. REGISTR ATION MARK

 N54321 

APPLICAT ION IS H EREBY MA DE FOR: (Check applicabl e items)

2. AIRCRAFT BU ILDER'S NAME (Make)

 P iper

3. AIRCRAFT MODEL DE SIGNATION FAA CODING

 P A18A - 150

4. YR. MFR.

 1951

7. ENGINE MODEL DE SIGNATION

 0- 320

10. PRO PELLER MODEL DESIG NATION

 M74DM IMPORT

11. AIRC RAFT IS (Check if appl icable)

DATE DISTRICT OFFICE DESIGNEE'S SIG NATURE AND NO. FAA INSPECTOR 'S SIGNATURE

 (Check ALL appli cable bloc ks in item s A and B)

A. I find that the aircr aft desc ribed in Sec tion I or VII meets requirements for

X X

NAME

North Central Airplane Corp.

ADDRESS Rt. 

1 Box 502 Cutbac k, 

Minn. 43692

B. AIRCRA FT CE RTIFICATIO N BAS IS (C heck appli cable bloc ks and complete items as indic ated)

X

C. AIRCRAFT OPERATION A ND MAINTENANCE RECORDS

CHECK IF RECORDS IN

 COMPLIANCE W ITH 

14 CF R section 91.417

TOTAL AIRFRAME HOURS

12,050 3

DATE OF APPLICATION

11/21/96

D. CERTIFICATION - I hereby certify that I am the regi ster ed owner (or his agent) of the aircr aft desc ribed above, that the ai rcraft i s registered with the Federal Av iati on A dministr ation in acc ordance with

Title 49 of the U nited States Code 44101 et seq. and appli cabl e Federal Av iati on R egul ations, and that the air craft has been i nspected and is airw orthy and el igible for the airworthi ness cer tifi cate

requested.

A. THE AIRCRAFT DES CRIBED ABOVE HAS B EEN IN SPECTED AND FOUND AIRW OR THY BY : (Complete this section only if 14 CFR part 21 .183( d) applies).

NAME AND T ITLE (Print or type)

John J ones, President

SIGNATURE

DATE TITLE SIGNATURE

INSTRUCTIONS - Print or type. Do not write in shaded areas; these are for FAA

use only. Subm it original only to an authorized FAA Representative. If additional

space is required, use attachm ent. For special flight perm its com plete Sections

II, VI, and VII as applicable.

B. Inspecti on for a special fli ght permit under Sec tion VII

 was c onducted by:

6. ENGINE BUILDER 'S NAME (Make)

 Lycoming

9. PROP ELLER B UILDER' S NAME (Make)

 Sensenich

5. AIRCR AFT SER IAL NO.

 18- 3792

8. NUMBER OF ENGINES

 One

IF DEALER, CHECK HERE

AIRCRAFT LISTING (Gi ve page number(s))

N/A

SUPPLEMENTAL TYPE CERTIFICAT E (Li st number of each ST C inc orpor ated)

AIRCRAFT MANUFA CTURER (Give name or firm) 

U.S. D epartment

of Tr ansportation

Federal Aviation

Administration

Certificate No.)

Form Approved

O.M .B. No. 2120-0018

X NORMAL X UTILITY ACROBATIC TRANSPORT COMMUTER BALLOON

FAA Form 8130-6 (5-01) Supersedes Previous Edition NSN: 0052-00-024-7006

C X MULTIPLE AIR W ORTHINESS CERTIFICATE (Check ABOVE " Restr icted Oper ation" and "Standard" or "Limi ted" as applicable.)

X

SPECIAL FLIGHT PERMIT (Indi cate 

oper ati on to be conduc ted, then

 complete S ecti on V I or VII as 

applicable on rev erse side)

LIMITED

PROVIS IONAL (Indicate class)

RESTRICTED (Indi cate operation( s) to

 be c onducted)

AGRICULTURE AN D PEST CONTROL

FOREST (W ildlife c onservation)

CLAS S I

CLAS S II

AERIAL

PATRO LLING

 AERIAL ADVER TISING

 WEATHER CONTROL

AMATEUR BUILT

CREW TRAINING

EXHIBITION

MARKET SURVEY

DELIVERIN G OR EX PORTING

TO SHOW COMPLIAN CE W ITH THE CFR

CUSTOMER DEMONSTRATION FLIGHTS

PRODUCTION FLIGHT TESTING

x

FERRY FLIGHT FOR R EPAIRS, A LTERATION S, MAINT ENANCE, O R STORAGE

EVACUATE FROM AREA OF IMPE NDING DANGER

OPERATION IN EX CESS OF MAX IMUM CERTIF ICATED TAKE -OFF W EIGHT

RESEARCH AND DEVELOPMENT

AIR RACING EXPERIM ENTAL (Indicate operati on(s)

 to be c onducted)

OTHER (Specify)

OPERATING (Primary Category) KIT BUILT AIRCRAFT 

PRIMARY

FAA INSPECTOR

14 CFR par t 65

FAA DE SIGNEE

14 CFR part 121 OR 135 14 CFR part 145

THE CERTIFICA TE REQUESTED

AMENDMENT OR MODIFICATION OF CURRENT AIRW ORTHINESS CERTIFICATE

CERTIFICATE HOLDER UNDER

1 OTHER

4 1

3 6

4

2

5

3

4

 8

3

6

3

2

5

1

2

4

1

0

7

4

0

7

5

4

3

2

1

5

7

2

5

6

5

2