## TEAR OFF DEPARTMENT OF TRANSPORTATION FEDERAL AVIATION ADMINISTRATION 

## BEFORE USING SUPPLEMENTAL INFORMATION
CERTIFICATION OF WAIVER OR AUTHORIZATION APPLICATION - PRIVACY ACT The information on the accompanying form is solicit ed under authority of Federal Aviation Regulations Parts 91, 101, and 105. Submission of the information is mandatory. The purpose of this information is to establish elig ibility for certificate of waiver or authorization The data will be used for recordkeeping and statistical purposes. Incomplete submission may result in delay or denial of your request.

FAA F o rm 7711-2 ( 8 / 08 ) Supersedes Prev ious Edi tion


### DETACH THIS PART BEFORE USING

## From Approved: O.M.B. N o.2120-0027 10 /31/2 015 APPLICANTS - DO NOT USE THESE SPACES

Action


### □ Approved 

### □ Disapproved – ”Explain under "Remarks" Signature of authorized FAA representative

8. Area of operation (Location, altitudes, etc.)

9a. Beginning (Date and hour) b. Ending (Date and hour)

10. Aircraft make and model (a) Pilot's Name (b) Certificate number and rating ( c ) Home address (Street, City, State) (d) No certificate may be issued unless a completed application form has been received (14 C.F.R. 91. 101. and 105).


## US Department of Transportation Federal Aviation Administration Region Date


# APPLICATION FOR CERTIFICATE OF WAIVER OR AUTHORIZATION
INSTRUCTIONS Submit this application in triplicate (3) to any FAA Flight Standards district office.
A pplicants requesting a Certificate of Waiver or Authorization for an aviation event must complete all the applicable items 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 in clude scale depictions of the flightlines, showlines, race courses, and the location of the air event control point, Police dispatch, ambulance, and fire fighting equipment. The applicant may also wish to submit photographs and scale diagrams as supplemental material to assist in the FA A's evaluation of a particular site. A pplication for a Certificate of Waiver or Authorization must be submitted 45 days prior to the requested date of the event.
A pplicants requesting a Certificate of Waiver or Authorization for activities other than an aviation event will complete items 1 through 10 only and the cert ification, item 1 7 , on the reverse. 1. Name of organization 2. Name of responsible person

3. Permanent House number and street or route number City State and ZIP code Telephone No.

mailing address

6. FA R section and number to be waived

.

7. Detailed description of proposed operation (Attach supplement if needed)



## FAA Form 771 1 -2 ( 8 / 08 ) S upersedes P revious E dition 4 . State whether the applicant or any of its principal officers/owners has an application for waiver pending at any other office of the FAA.

5 . State whether the applicant or any of its principal officers owners has ever had its application for waiver denied, or wheth er the FAA has ever withdrawn a waiver from the applicant or any of its principal officers/owners.



# 1BHFITEMS 11 THROUGH 1 6 TO BE FILLED OUT FO R AIR SHOW/AIR RACE WAIVER REQUESTS ONLY. 11. The air event will be sponsored by:

If sufficient space is not available, the entire schedule of events may be submitted on separate sheets, in the order and manne r indicated above. 

### The undersigned applicant accepts full responsibility for the strict observance of the terms of the Certificate Please Read of Waiver or Authorization, and understands that the authorization contained in such certificate will be strictly limited to the above described operation. 17. Certification - I CERTIFY that the foregoing statements are true. □ 

### Physician

□ 

### Ambulance □ 

### Fire truck

□ 

### Crash wagon □ 

### Other - Specify 12. Permanent House number and street or route number City State and ZIP code Telephone No. mailing address
13. Policing (Describe provisions to be made for policing the event.)

14. Emergency facilities (Mark all that will be available at time and place of air event.)

15. Air Traffic control (Describe method of controlling traffic, including provision for arrival and departure of scheduled aircraft.)

16. Schedule of Events (include arrival and departure of scheduled aircraft and other periods the airport maybe open.)

Hour Date Event (a) (b) (c)

Date Signature of Applicant

Remarks



### FAA F orm 77 11-2 ( 8 / 08 ) S upersedes Previous E dition 

# 1BHF