U.S. Department of Transportation INFORMATION FOR APPLICANT Federal Aviation Administration APPLICATION FOR U.S. AIRWORTHINESS CERTIFICATE Privacy Act Statement Information on FAA Form 8130-6, Application for U.S. Airworthiness Certificate is solicited under the authority of 49 U.S.C. 44103 as implemented by 14 CFR Part 21. The purpose of this information is to evaluate an applicant's application for a U.S. Airworthiness Certificate. Submission of this data is mandatory and will become part of the Privacy Act system of records DOT/FAA 801, Aircraft Registration System. Incomplete submission may result in delay or denial of your request. Information maintained in the Privacy Act system of records is routinely used t o (1) provide aircraft owners and operators information about potential mechanical defects or unsafe conditions of their aircraft in the form of airworthiness directives, (2) locate specific individuals or aircraft for accident investigation, violation, or safety related requirements, (3) prepare an Aircraft Registry in magnetic tape and microfiche form as required by ICAO agreement, containing information on aircraft owners by name, address, United States Registration Number, and type of aircraft, and (4) DOT Prefatory Statement of General Routine Uses.*****This is the test version not for Production****** Paperwork Reduction Act Statement: This information is collected for the purpose of issuing a U.S. Airworthiness Certificate to any applicant meeting the criteria established in FAA Order 8130-2, Airworthiness Certification of Aircraft and Related Products. The FAA uses the information to maintain and update the current database of aircraft having obtained approved airworthiness certificates. The information is protected under the provisions of the Privacy Act and the Privacy Act System of records DOT/FAA-801, Aircraft Registration System. 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 of information is 2120-0018. 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. TEAR OFF THIS COVER SHEET BEFORE SUBMITTING THIS FORM FAA Form 8130-6 (01-09) Previous Edition Dated 5/01 May be Used Until Depleted, Except for Light-Sport Aircraft NSN: 0052-00-024-7006 American LegalNet, Inc. www.FormsWorkflow.com FAA FORM 8130-6, APPLICATION FOR U.S. AIRWORTHINESS CERTIFICATE Form Approved O.M.B. No. 2120-0018 12/31/2010 APPLICATION FOR U.S. AIRWORTHINESS CERTIFICATE I. AIRCRAFT DESIGNATION U.S. Department of Transportation Federal Aviation Administration 1. REGISTRATION MARK INSTRUCTIONS - Print or type. Do not write in shaded areas; these are for FAA use only. Submit original only to an authorized FAA Representative. If additional space is required, use attachment. For special flight permits complete Sections II, VI and VII as applicable. 4. YR. MFR. FAA CODING 2. AIRCRAFT BUILDER'S NAME (Make) 3. AIRCRAFT MODEL DESIGNATION 5. AIRCRAFT SERIAL NO. 6. ENGINE BUILDER'S NAME (Make) 7. ENGINE MODEL DESIGNATION 8. NUMBER OF ENGINES 9. PROPELLER BUILDER'S NAME (Make) 10. PROPELLER MODEL DESIGNATION 11. AIRCRAFT IS (Check if applicable) IMPORT APPLICATION IS HEREBY MADE FOR: (Check applicable items) A STANDARD AIRWORTHINESS CERTIFICATE (Indicate Category) 1 B NORMAL ACROBATIC UTILITY 7 BALLOON OTHER PRIMARY 9 LIGHT-SPORT (Indicate Class) 2 LIMITED 5 PROVISIONAL (Indicate Class) AIRPLANE POWER-PARACHUTE GLIDER WEIGHT-SHIFT-CONTROL LIGHTER THAN AIR AERIAL SURVEY 3 AERIAL ADVERTISING 5 PATROLLING 6 WEATHER CONTROL OTHER (Specify) RESEARCH AND DEVELOPMENT 2 AMATEUR BUILT 3 EXHIBITION AIR RACING 5 CREW TRAINING 6 MARKET SURVEY 0 TO SHOW COMPLIANCE WITH THE CFR 7 OPERATING (Primary Category) KIT BUILT AIRCRAFT 8 4 2 FOREST (Wildlife Conservation) 4 EXPERIMENTAL (Indicate AGRICULTURE AND PEST CONTROL 4 1 to be conducted) CLASS II 0 RESTRICTED (Indicate operation(s) 3 CLASS I 2 1 II. CERTIFICATION REQUESTED 1 OPERATING LIGHT-SPORT operation(s) to be conducted) 8A Existing Aircraft without an airworthiness certificate & do not meet § 103.1 8B Operating Light-Sport Kit-Built 8C Operating light-sport previously issued special light-sport category airworthiness certificate under § 21.190 1 6 2 EVACUATION FROM AREA OF IMPENDING DANGER (Indicate operation(s) to be conducted, then complete Section VI or VII as applicable on reverse side) 3 OPERATION IN EXCESS OF MAXIMUM CERTIFICATED TAKE-OFF WEIGHT 4 DELIVERING OR EXPORTING 6 C FERRY FLIGHT FOR REPAIRS, ALTERATIONS, MAINTENANCE, OR STORAGE SPECIAL FLIGHT PERMIT 8 CUSTOMER DEMONSTRATION FLIGHTS 5 PRODUCTION FLIGHT TESTING MULTIPLE AIRWORTHINESS CERTIFICATE (check ABOVE "Restricted Operation" and "Standard" or "Limited" as applicable) A. REGISTERED OWNER (As shown on certificate of aircraft registration) IF DEALER, CHECK HERE ADDRESS NAME III. OWNER'S CERTIFICATION COMMUTER TRANSPORT SPECIAL AIRWORTHINESS CERTIFICATE (Check appropriate items) B. AIRCRAFT CERTIFICATION BASIS (Check applicable blocks and complete items as indicated) AIRCRAFT SPECIFICATION OR TYPE CERTIFICATE DATA SHEET (Give No. and AIRWORTHINESS DIRECTIVES (Check if all applicable AD's are compiled with and give the Revision No.) number of the last AD SUPPLEMENT available in the biweekly series as of the date of application) AIRCRAFT LISTING (Give page number(s)) SUPPLEMENTAL TYPE CERTIFICATE (List number of each STC incorporated) C. AIRCRAFT OPERATION AND MAINTENANCE RECORDS EXPERIMENTAL ONLY (Enter hours flown since last certificate issued or TOTAL AIRFRAME HOURS CHECK IF RECORDS IN 3 renewed) COMPLIANCE WITH 14 CFR Section 91.417 D. CERTIFICATION - I hereby certify that I am the registered owner (or his agent) of the aircraft described above, that the aircraft is registered with the Federal Aviation Administration in accordance with Title 49 of the United States Code 44101 et seq. and applicable Federal Aviation Regulations, and that the aircraft has been inspected and is airworthy and eligible for the airworthiness certificate requested. SIGNATURE NAME AND TITLE (Print or type) DATE OF APPLICATION IV. INSPECTION AGENCY VERIFICATION A. THE AIRCRAFT DESCRIBED ABOVE HAS BEEN INSPECTED AND FOUND AIRWORTHY BY: (Complete the section only if 14 CFR part 21.183(d) applies. 14 CFR part 121 CERTIFICATE HOLDER 2 3 (Give Certificate No.) CERTIFICATED MECHANIC (Give Certificate No.) AIRCRAFT MANUFACTURER (Give name or firm) 5 SIGNATURE TITLE DATE THE CERTIFICATE REQUESTED (Check ALL applicable block items A and B) V. FAA REPRESENTATIVE CERTIFICATION CERTIFICATED REPAIR STATION (Give Certificate No.) 6 A. I find that the aircraft described in Section I or VII meets requirements for B. Inspection for a special permit under Section VII was AMENDMENT OR MODIFICATION OF CURRENT AIRWORTHINESS CERTIFICATE FAA INSPECTOR FAA DESIGNEE CERTIFICATE HOLDER UNDER conducted by: DATE 4 14 CFR part 65 4 14 CFR part 121 OR 135 14 CFR part 145 FAA INSPECTOR'S SIGNATURE DESIGNEE'S SIGNATURE AND NO. MIDO/FSDO Office 1 FAA Form 8130-6 (01-09) Previous Edition Dated 5/01 May be Used Until Depleted, Except for Light-Sport Aircraft NSN: 0052-00-024-7006 American LegalNet, Inc. www.FormsWorkflow.com A. MANUFACTURER VI. PRODUCTION FLIGHT TESTING NAME ADDRESS B. PRODUCTION BASIS (Check applicable item) PRODUCTION CERTIFICATE (Give production certificate number) TYPE CERTIFICATE ONLY APPROVED PRODUCTION INSPECTION SYSTEM C. GIVE QUANTITY OF CERTIFICATES REQUIRED FOR OPERATING NEEDS DATE OF APPLICATION NAME AND TITLE (Print or Type) SIGNATURE A. DESCRIPTION OF AIRCRAFT REGISTERED OWNER ADDRESS BUILDER (Make) MODEL SERIAL NUMBER REGISTRATION MARK VII. SPECIAL FLIGHT PERMIT PURPOSES OTHER THAN PRODUCTION FLIGHT TEST B. DESCRIPTION OF FLIGHT FROM CUSTOMER DEMONSTRATION FLIGHTS TO VIA (Check if applicable) DEPARTURE DATE DURATION C. CREW REQUIRED TO OPERATE THE AIRCRAFT AND ITS EQUIPMENT PILOT CO-PILOT FLIGHT ENGINEER OTHER (Specify) D. THE AIRCRAFT DOES NOT MEET THE APPLICABLE AIRWORTHINESS REQUIREMENTS AS FOLLOWS: E. THE FOLLOWING RESTRICTIONS ARE CONSIDERED NECESSARY FOR SAFE OPERATION: (Use attachment if necessary) F. CERTIFICATION – I hereby certify that I am the registered owner (or his agent) of the aircraft described above; that the aircraft is registered with the Federal Aviation Administration in accordance with Title 49 of the United States Code 44101 et seq. and applicable Federal Aviation Regulations; and that the aircraft has been inspected and is safe for the flight described. VIII. AIRWORTHINESS DOCUMENTATION (FAA/DESIGNEE use only) DATE NAME AND TITLE (Print or Type) SIGNATURE A. Operating Limitations and Markings in Compliance with 14 CFR Section 91.9, as applicable. G. Statement of Conformity, FAA Form 8130-9 (Attach when required) B. Current Operating Limitations Attached H. Foreign Airworthiness Certification for Import Aircraft (Attach when required) C. Data, Drawings, Photographs, etc. (Attach when required) I. Previous Airworthiness Certificate Issued in Accordance with D. Current Weight and Balance information Available in Aircraft 14 CFR Section E. Major Repair and Alteration, FAA Form 337 (Attach when required) J. Current Airworthiness Certificate Issued in Accordance with 14 CFR Section F. This inspection Recorded in Aircraft Records K. Light-Sport Aircraft Statement of Compliance, FAA Form 8130-15 (Attach when required) FAA Form 8130-6 (01-09) Previous Edition Dated 5/01 May be Used Until Depleted, except for Light-Sport Aircraft CAR (Original Attached) (Copy Attached) NSN: 0052-00-024-7006 American LegalNet, Inc. www.FormsWorkflow.com