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# 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 

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

# L elephone No. mailing / / /{ ~~]~ 

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# I ` ~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.



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# 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or any of its principal officers owners has ever had its application for waiver deriied, or whether the FAA has ever withdrawn a waiver from the applicanl or , any of its pnncipal ofticers/owners.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) 

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10. Aircraft Pilot's Name make and model a (b) 

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# WA 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 mailin g address House number and street or route number cit y State and ZIP code Telephone No.

13. 

### Policin g (Describe provisions to be made for policin g the event.)



### 14 Emer g enc y fadlibes (Mark all that viill be available at time and place of air event) 

### Ph y sician Fire truck ❑ 

### Other - 

### Specif y ❑ 

### Ambulance ❑ Crash wa g on 15. 

### Air Traffic control (Describe method ofcontrollin g traffic, includin g provision foramval anddeparture of scheduled aircraft.)

16 

### Sr-hedule of Events (include arrival and depa(ture of scheduled aircraft and other peiiods the aitport ma y be 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 undersi g ned applicant accepts full responsibilit y for 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 g nature of,A,,pn

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