US Department of Transportation Federal Aviation Administration AGRICULTURAL AIRCRAFT OPERATOR CERTIFICATE APPLICATION Paperwork Reduction Act Statement: The information collected on this form is required. This form is submitted to determine eligibility for the issuance of the Agriculture Aircraft Operator Certificate. Confidentiality is neither requested nor provided. We estimate that it will take 1 hour to complete the form. Please note that an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number associated with this collection is 2120-0049. Comments concerning the accuracy of this burden and suggestions for reducing the burden should be directed to the FAA at: 800 Independence Ave. SW, Washington, DC 20591 Attn: Information Collection Clearance Officer, ABA-20 SUPPLEMENTAL TEAR OFF BEFORE USE Form 8710-3 (10-83) INFORMATION DETACH THIS PART BEFORE USING FORM BELOW American LegalNet, Inc. www.FormsWorkflow.com Form Approved OMB No. 2120-0049 05/31/2009 INSTRUCTIONS Submit in duplicate to the local General Aviation District Office. AGRICULTURAL AIRCRAFT OPERATOR CERTIFICATE APPLICATION US Department of Transportation Federal Aviation Administration TYPE 1. APPLICATION FOR FOR DISPENSING (Check one) ORIGINAL PRIVATE ECONOMIC POISONS AMENDMENT COMMERCIAL OTHER THAN ECONOMIC POISONS REISSUANCE 2. NAME AND ADDRESS OF APPLICANT 3. PRINCIPAL OPERTIONS BASE (Airport, City, State) TELEPHONE NUMBER TELEPHONE NUMBER INDIVIDUAL 2. OPERATING AS OTHER (Specify) 5. NAME OF CHIEF SUPERVISOR OF OPERATIONS IF OTHER THAN SHOWN IN ITEM 2. (COMMERCIAL OPERATIONS ONLY) CORPORATION PARTNERSHIP (First) 6. AIRMAN CERTIFICATE HELD (Middle Initial) CERTIFICATE NUMBER (Last) RATINGS GRADE TYPE RATING(S) (Specify) PRIVATE ASEL AMES COMMERCIAL AMEL HELICOPTER AIRLINE TRANSPORT ASES GYROPLANE 7A. NO YES (Complete 7B) DO YOU HOLD A CURRENTLY EFFECTIVE CERTIFICATE OF WAIVER FOR CONDUCTING AGRICULTURAL AIRCRAFT OPERATIONS? 7B. WAIVER HELD DATE ISSUED EXPIRATION DATE FAA DISTRICT OFFICE WHERE ISSUED 8. AGRICULTURAL AIRCRAFT TO BE OPERATED MAKE EQUIPPED FOR MODEL LIQUID SOLID TOTAL NUMBER EACH AIRCRAFT OPERATED REGISTRATION MARK (List one) 9. LIST THE NAME(S) AND AIRMAN CERTIFICATE NUMBER OF AGRICULTURAL PILOT(S) WORKING FOR YOU AT THE PRESENT TIME (Use separate sheet and attach if additional space is needed.) NAME CERT. NO. NAME CERT. NO. 10. REMARKS 11. CERTIFICATION: I CERTIFY THAT STATEMENTS MADE ON THIS FORM ARE TRUE AND CORRECT. DATE FAA Form 8710-3 TITLE (10-83) SIGNATURE American LegalNet, Inc. www.FormsWorkflow.com INSPECTION REPORT - For FAA Use Only (To be completed by the General Aviation for Flight Standards District Office) COMPLIANCE WITH APPLICABLE REGULATIONS 1. PILOTS NOT REQUIRED SATISFACTORY UNSATISFACTORY A. CERTIFICATES B. RATING(S) C. KNOWLEDGE TEST D. SKILL TEST 2. AIRCRAFT A. CERTIFICATED B. AIRWORTHY C. EQUIPPED FOR AGRICULTURAL OPERATIONS 10. REMARKS (Include an explanation of denial if application is disapproved). 4. DISTRICT OFFICE ACTION CERTIFICATE ISSUED INSPECTORS SIGNATURES APPLICATION DISAPPROVED DATE INSPECTION COMPLETED American LegalNet, Inc. www.FormsWorkflow.com