Appendix 13 APPENDIX 13. SAMPLE PROGRAM LETTER TO ACCOMPANY
APPLICATION FOR AIRWORTHINESS CERTIFICATE [Insert local FAA office or DAR] Date: [Insert date]
TO:
In accordance with 14 CFR § 21.193, I request a Special Airworthiness Certificate for my aircraft for the purpose of operating amateur-built aircraft. The aircraft description is as follows:
Builder: Early A. Builder Registration No.: N130EA Model: VAN’S RV-6 Serial No.: 1001 No. of Engines: 1 No. of Seats: 2 Design Criteria: my own design built from plans built from a kit X The aircraft is complete and the following items have been accomplished:
Yes No I enclose FAA Form 8130-6 with Sections I, II, and III complete.
Yes No I enclose FAA Form 8130-12 with Sections I, II, and III complete and notarized in Section IV.
Yes No I possess Aeronautical Center Form 8050-3.
Yes No I enclose a three-view drawing or photographs of the aircraft.
Yes No I have weighed the aircraft to determine that the most forward and aft center of gravity positions are within established limits. The weight and balance report is available at the aircraft, and a copy is submitted with this application.
Yes No I have maintained a construction log for the project, including photographs showing methods of construction and workmanship during the construction. Log entries describe all inspections conducted during construction.
Yes No The marking requirements of part 45 have been complied with, including permanent attachment of a fireproof identification (data) plate, permanent application of appropriate registration marks, and the word “experimental” displayed near each entrance to the cabin or cockpit.
Yes No The following placard is displayed in the cockpit in full view of all occupants (not required for single-place aircraft).
“PASSENGER WARNING—THIS AIRCRAFT IS
AMATEUR-BUILT AND DOES NOT COMPLY WITH
FEDERAL SAFETY REGULATIONS FOR STANDARD AIRCRAFT.”
13-1
Appendix 13 APPENDIX 13. SAMPLE PROGRAM LETTER TO ACCOMPANY
APPLICATION FOR AIRWORTHINESS CERTIFICATE (CONTINUED) The aircraft will be available for inspection at this location, and directions are as follows:
Grayson County Airport Hangar No. 3 4701 Airport Dr.
Sherman, TX 75020 I request airworthiness certification and operation limitations be issued permitting me to operate the aircraft within the following geographical area for flight testing. Initial flights will determine engine reliability and flight control characteristics. A flight test plan has been developed using the guidance in AC 90-89 and is available for review. After Phase I flight test completion, I plan to operate the aircraft under VFR conditions only.
25-statute mile radius of Grayson County Airport Latitude, 33-43 N; Longitude, 096-40W Dallas-Ft. Worth Sectional (L13) My residential telephone number is (903) 555-1212.
My daytime business number is (214) 555-1212.
Early A. Builder Early A. Builder Owner/Builder 13-2
Appendix 14 APPENDIX 14. SAMPLE FAA FORM 8610-2, AIRMAN CERTIFICATE
AND/OR RATING APPLICATION TYPE OR PRINT ALL ENTRIES IN INK Form Approved OMB No. 2120-0022 US Department of Transportator Federal Aviation Adininistration
AIRMAN CERTIFICATE AND/OR RATING APPLICATION
•MECHANIC 2 REPAIRMAN • PARACHUTE RIGGER
•AIRFRAME • POWERPLANT EXPERIMENTAL AIRCRAFT BUILDER • SENIOR O SEAT •MASTER • CHEST (Specify Rating) •BACK O LAP PLICATION FOR: 4 ORIGINAL ISSUANCE • ADDED RATING A. NAME (First. Middle, Last) K. PERMANENT MAILING ADDRESS Early A. INITIAL ONLY Builder 1240 Bois d' Arc Road I. APPLICANT INFORMATION B. SOCIAL SECURITY NO. 123-45-6789 C. DOB (Mo.Day Yr.) 12-12-1943 D. HEIGHT 76 JE. WEIGHT 235 NUMBER AND STREET. P.O. BOX, ETC IN.
F. HAIR G. EYES H. SEX T. NATIONALITY (Citizenship) Savoy_ brown brown M USA cty-- J. PLACE OF BIRTH TX 75479 Bug Tussle, TX STÄTE™ ZIP CODE L. HAVE YOU EVER HAD AN AIRMAN CERTIFICATE SUSPENDED OR REVOKED? M. DO YOU NOW OR HAVE YOU EVER HELD AN FAA AIRMAN "EMO BrES
CERTIFICATE
•YES (If "Yes." explain anacneo sneet ке lo approprate nem numperj SPECIFY TYE Private Pilot N. HAVE YOU EVER BEEN CONVICTED FOR ' TOLATION OF ANY FEDERAL OR STATE STATUTES DATE OF FINAL CONVICTION
PERTA NING TO NARCOC DRUGS MARIJUANA DRUGS OR SUBSTANCES? . . KI NO OYES -
•A. CIVIL • B. MILITARY •C. LETTER OF RECOMMENDATION FOR II. CERTIFICATE OR RATING APPLIED FOR EXPERIENCE (1) NAME AND LOCATION OF SCHOOL EXPERIENCE REPAIRMAN ((Attach copy) ON BASIS OF - L ° OF APPAOE OF APPROVED COURSE (2) SCHOOL NO. (3) CURRICULUM FROM WHICH GRADUATED (4) DATE
(1) SCHOOL NAME NO. (2) SCHOOL OFFICIAL'S SIGNATURE
AND IS RECOMMENDED TO TAKE THE ORAL/
• F MPECIAL AUTHORIZATION TO TAKE PRACTICAL TEST (FAR 65.80) (1) DATE AUTH. (2) DATE AUTH. EXPIRES (3) FAA INSPECTOR SIGNATURE (4) FAR DIST OFC
MECHANIC'S ORAL/PRACTICAL TEST (FAR 65.80) A. MILITARY (1) SERVICE (2) RANK OR PAY LEVEL (3) MILITARY SPECIALTY CODE
COMPETENCE
OBTAINED IN B. APPLICANTS OTHER THAN FAA CERTIFICATED SCHOOL GRADUATES, LIST EXPERIENCE RELATING TO CERTIFICATE AND RATING APPLIED FOR.
(Continue on separate sheet. if more space is needed) III. RECORD OF EXPERIENCE DATES-MONTH AND YEAR
TYPE WORK PERFORMED
FROM TO MAKE - Builder MODEL - Van's RV-6 SERIAL No. - 1001
CERTIFICATION DATE
OF AIRCRAFT
SEAT CHEST BACK LAP FOR PACKED AS A - C. PARACHUTE RIGGER APPLICANTS: INDICATE BY TYPE HOW MANY MASTER RA LING • SENIOR O MILITARY
PARACHUTES PACKED ONLY RIGGER
I CERTIFY THAT THE STATEMENTS BY ME ON THIS APPLICATION ARE TRUE IV. APPLICANT'S CERTIFICATION A. SIGNATURE Eady A. Builler B. DATE XXXX-XXXX
I FIND THIS APPLICANT MEETS THE EXPER- INSPECTOR'S SIGNATUF FAA DISTRICT OFFICE
v. IENCE REQUIREMENTS OF FAR 65 AND IS
ELIGIBLE TO TAKE THE REQUIRED TESTS
FOR FAA USE ONLY Emp. reg. D.O seal con iss Act Tlev [TR s.h. Sich Arie RATING (1) RATING (2) RATING (3) RATING (4) FAA Form 8610-2 (2-85) SUPERSEDES PREVIOUS EDITION TU.S.G.P.O.: 1993-769-012/80055 14-1