rorm nas aeen recetvea t-m c.r.tc. yi. -rui. ana iuo/. 

f-t US Department of Transportation 

w Federal Aviation Administration 

From Approved: O.M.B. No.2120-0027 10/31/2015 

APPLICANTS - DO NOT USE THESE SPACES 

Region I Date 

APPLICATION FOR 

CERTIFICATE OF WAIVER 

OR AUTHORIZATION 

Action 

E]Approved ~ Disapproved — -Explain under "Remarks" 

Signature of authorized FAA representative 

Submit this application in triplicate (3) to any FAA Flight 

Standards district office. 

Applicants requesting a Certificate of Waiver or Authorization for an aviation event must complete all the applicable 

itenis on this form and attach a properly marked 7.5 series 

Topographic Quadrangle Map(s), published by the U.S. 

Geological Survey (scale 1:24,000), of the proposed operating area. The map(s) must include scale depictions of the 

flightlines, showfines, race courses, and the location of the 

air event control point, Police dispatch, ambulance, and fire 

1. Name of organization 

INSTRUCTIONS 

fighting equipment. The applicant may also wish to submit 

photographs and scale diagrams as supplemental material 

to assist in the FAA's evaluation of a particular site. 

Application for a Certificate of Waiver or Authorization must 

be submitted 45 days prior to the requested date of the 

event. 

Applicants requesting a Certificate of Waiver or Authorization for activities other than an aviation event will complete 

items 1 through 10 only and the certification, item 17, on the 

reverse. 

2. Name of responsjble person 

L, - E/,A 1~ -r-, . V\,~ ,rq c-i ~j ~ 

3 Permanent House number and street or route number Cily State and ZIP code 

L

elephone No. 

mailing / / /{ ~~]~ '/l address 

/1 t ,! 1 L . ~A1 Jl ~ ~QIv) ~'G/ ~-lI ` ~C~' ~t G' 

4 Stato whether Uie appli~ or any of its pnncipal officerslowners has an aplication for v ✓aiver pending at any other office of the FAA. 

~V A 

5 State wheUier the applicant or any of its principal officers owners has ever had its application for waiver deriied, or whether the FAA has ever withdrawn a waiver from the applicanl or , any of its 

pnncipal ofticers/owners. 

N /A 

6 FAR section and number to be svaived 

PA k ~ ~ ( 

7 Detailed description of proposed operation (Aftach supplement if needed) 

N+a -r(o tir P ( etL) RC AN 1~ iE ~j F 11-r~ 

V~ r'~~. ~ 5 I~ l E 5 GF-AvI rM I C./A ; f~ I~;` ~). c C> i7 i• AuT I TU b f —_ 

10. Aircraft Pilot's Name make and model 

a (b) 

jWA D 21 rke) 

ificate number Home address 

and rating (Street. City, Stale) 

c 

FAA Form 7711 -2 (8/08) Supersedes Previous Edition Page 1 
~ ITEMS 11 THROUGH 16 TO BE FILLED OUT FOR AIR SHOWIAIR RACE WAIVER REQUESTS ONLY. 

11. The air event will be sponsored b y 

12 Permanent 

mailing 

address 

House number and street or route number city State and ZIP code Telephone No. 

13. Policing (Describe provisions to be made for policin gthe event.) 

14 Emergencyfadlibes (Mark all that viill be available at time and place of air event) 

Physician Fire truck ❑ Other - Specify 

❑ Ambulance ❑ Crash wa gon 

15. Air Traffic control (Describe method ofcontrollin gtraffic, includin gprovision foramval anddeparture of scheduled aircraft.) 

16 Sr-hedule of Events (include arrival and depa(ture of scheduled aircraft and other peiiods the aitport ma ybe open.) 

Hour 

(a) 

Date 

(b) 

Event 

(c) 

If sufficient space is not available, the enfire schedule of events ma y be submitted an separate sheets, in the order and manner indicated above. 

The undersigned applicant accepts full responsibilityfor the stdct observance of the terms of the Certificate 

Please Re > of Waiver or Authorization, and understands that the authorization contained in such certificate will be strictl y 

limited to the above described operation. 

17. Certification - I CERTIFY that the foregoing statements are true. 

Date Si gnature of,A,,pn 

Re arks 

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