### From Approved: O.M.B. No.2120-0027 08/31/2008

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. F A R section and number to be waived

.

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



### FAA Form 771 1 -2 ( 8-08 ) Supersedes Previous Edition 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or any of its principal officers owners has ever had its application for waiver denied, or wheth er the FAA has ever withdrawn a waiver from the applicant or any of its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.ITEMS 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 Form 7711-2 ( 8-08 ) Supersedes Previous Edition