DOA, DAS, SFAR 36 STATEMENT OF QUALIFICATIONS Form Approved OMB-2120-0018 09/30/2007 Paperwork Reduction Act Statement: This collection of information is to obtain information concerning the applicant's qualifications to act as an FAA-delegated organization. The FAA uses the information to determine the suitability of the organization to issue FAA design and airworthiness approvals. The submittal of this information is mandatory for applicants to be considered, and promise of confidentiality is neither provided nor necessary. The burden associated with new applications using this form is 2 hours. 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 number. The OMB control number associated with this collection of information is 2120-0018. Comments concerning the accuracy of this buden and suggestions for reducing the burden should be directed to the FAA at: 800 Independence Ave. Washington, DC 20591, Attn: Information Collection Clearance Officer, ABA- 20. 2. PHONE NUMBER: 1. COMPANY NAME: 3. COMPANY ADDRESS: (Number, street, city and ZIP code) 4. TYPE OF DELEGATION SOUGHT: DOA DAS SFAR 36 5. FUNCTIONS SOUGHT: (Applicants shall identify below the specific function(s) currently authorized in FAA Order 8100.9 for which appointment is sought, and identify any limitations based on experience, e.g., type and complexity of the product) 6. EXPERIENCE WORKING WITH THE FAA AS APPROPRIATE FOR THE TYPE OF AUTHORIZATION SOUGHT: (Use additional sheets as necessary) 7. HOLD THE FOLLOWING FAA CERTIFICATE(S) REQUIRED FOR ELIGIBILITY OF THE DELEGATION SOUGHT: Type Certificate Number Ratings Date Each Rating Issued 8. LOCATION(S) WHERE THE DELEGATED FUNCTIONS WILL BE PERFORMED: (Use additional sheets as necessary) 9. CERTIFICATION: I certify that the above statements are true to the best of my knowledge and that the organization is familiar with the Federal Aviation Regulations pertinent to the delegation sought. Date FAA Form 8100-10 (10-03) Signature (Management representative of company requesting delegation) NSN: 0052-00-924-2000 American LegalNet, Inc. www.FormsWorkflow.com -