9/30/2003 AC21-2K APPENDIX 1. SAMPLE FORMS (CONTINUED) Figure 3. Completed FAA Form 8130-4, Export Certificate of Airworthiness - Issued for Class I Products The nited States of America Department of Transportation Federal Abiation Administration No. E30016 400 ashington, .C.
Export Certificate of Airworthiness This certifies that the product identified beluw and mure particularly descrived in Specification (a) "of the Federal Aviation Administration, Numbered 6A17, E88, and P99 has been examined and as of the date of this certificate, is considered airworthy in accordance with a comprehensive and detailed airworthiness code of the United States Government, and is in compliance with those special requirements of the importing country filed with the United States Government, except as noted below. This certificate in no way attests to compliance with any agreements or contracts belween the vendor and purchaser, nor does it constilute authority to sperate an aircraft.
Product: Airplane Engine Model AIRECO IO-470-2 Manufacturer: ABC Airplane COXP. Serial Nos. 18976 and 18978 Total Time 50 hrs. and 51 hrs.
Model: C-5 Perial No.: 2468 Propeller Model Senhart SC-82XK-2 hub with New D Newly Overhauled D X8498C-2 blades, Hub Serial Nos. 21375 and 21412 Used Sircraft I Total time 50 hrs. and 51 hrs.
bountry to which exported: Japan oxceptions: A temporary auxiliary fuel system has been installed in this aircraft in conformity with ABC Drawing 123,Rev.l to facilate its delivery flight. This certificate is valid when the temporary installation is removed.
Total time since annual type inspection IAW 14 CFR part 43:
Aircraft 2 hours Engine(s) 2 hours (L/H) S/N 18976, 2 hours (R/H) S/N 18978.
Propeller (s) 2 hours (L/H) S/N 21375, 2 hours (R/H) S/N 21412.
Smith, FAA Designated Airworthiness Representative Signature of Authorized Representative December 18, 1996 ABC Airplane Corp. (PC75) Date District Office or Designee Number For complete aircraft, list applicable specification or Type Certificate Data Sheet numbers for the aircraft, engine, and propelle pplicable specifications or Type Certificate Data Sheet, if not attached to this export certificate, will have been forwarded to th appropriate governmental office of the importing country.
FAA Form 8130-4 (7-68) Formerly For FAA 26 * U.S. GOVERNMENT PRINTING OFFICE: 1974 - 773-234/139/7 Page 3 (and 4)
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APPENDIX 3. FAA AIRCRAFT CERTIFICATION OFFICE AND FAA INTERNATIONAL
FLIGHT STANDARDS FIELD OFFICE CONTACTS FOR OTHER COUNTRIES
FAA AIRCRAFT CERTIFICATION OFFICE ADDRESSES1 Country or Geographic Area International Mailing Address
a. Canada Federal Aviation Administration Aircraft Certification Office, ANE-170 10 Fifth Street, 3rd Floor Valley Stream, New York 11581-1200 Commercial: (516) 256-7500 FAX: (516) 568-2716
b. Caribbean Area, South America, and Central America (excluding Mexico) Federal Aviation Administration Aircraft Certification Office, ACE-115A One Crown Center 1895 Phoenix Boulevard, Suite 450 Atlanta, Georgia 30349-5580 Commercial: (770) 703-6035 FAX: (770) 703-6097
c. Mexico Federal Aviation Administration Rotorcraft Directorate, ASW-100 2601 Meacham Boulevard Fort Worth, Texas 76137-4296 Commercial: (817) 222-5100 FAX: (817) 222-5959
d. Area east of Bangladesh and India, including all free nations south and east of China Federal Aviation Administration Aircraft Certification Office, ANM-100L 3960 Paramount Boulevard Lakewood, CA 90712-4137 Commercial: (562) 627-5200 FAX: (562) 627-5210
1 The Aircraft Certification Offices listed should be contacted if the responsible FAA project office is not otherwise known. U.S.
companies should forward applications and coordinate activities with other countries through their local Aircraft Certification Office. Inquiries can also be directed to FAA headquarters, International Airworthiness Programs Staff, (202) 267-7008.
AC21-2K 9/30/2003
APPENDIX 3. FAA AIRCRAFT CERTIFICATION OFFICE AND FAA INTERNATIONAL
FLIGHT STANDARDS FIELD OFFICE CONTACTS FOR OTHER COUNTRIES (CONTINUED)
e. Europe, Africa, Middle East west of Myanmar, Iceland, Greenland, and Bermuda Federal Aviation Administration Brussels Aircraft Certification Staff 15 Rue de la Loi B-1040 Brussels, Belgium Federal Aviation Administration (Mailing Address) c/o American Embassy PSC 82 Box 002 APO AE, New York 09724-1011 Commercial: (32) 2 513 3830 FAX: (32) 2 230 3333
FAA INTERNATIONAL FLIGHT STANDARDS FIELD OFFICES
Country or Geographic Area International Mailing Address
a. Belgium, Israel, Jordan, Luxembourg, Netherlands, Oman, Saudi Arabia, United Arab Emirates, and Yemen Federal Aviation Administration Flight Standards International Field Office- Brussels 27 Blvd. du Regent B-1000 Brussels, Belgium c/o American Embassy (Mailing Address) PSC 82 Box 002 APO, AE, New York 09724-1011 Commercial: (32) 2 513 3830, ext. 2721 FAX: (32) 2 230 0534
Federal Aviation Administration Flight Standards International Field Office-Frankfurt Rhein Main Air Base, Unit 7580 60549 Frankfurt/Main 75
b. African Continent, European areas not covered by other IFOs, Russia and states formerly in the USSR, and Middle Eastern areas not covered by Brussels going to and including Iran.
FAA Frankfurt IFO, EA33 (Mailing Address) Unit 7580 APO, AE 09050 Commercial: (49-69) 69-705-110 FAX: (49-69) 69-705-150
9/30/2003 AC21-2K APPENDIX 3. FAA AIRCRAFT CERTIFICATION OFFICE AND FAA INTERNATIONAL
FLIGHT STANDARDS FIELD OFFICE CONTACTS FOR OTHER COUNTRIES (CONTINUED)
Federal Aviation Administration London International Field Office Sipson Court West Drayton, Middlesex UB7 OJD England, U.K.
c/o American Embassy (Mailing Address) PSC 801 Box 63 FPO, AE 09498
c. England Commercial: (44) 1293.573938 FAX: (44) 1293.573992 FAA/Singapore Flight Standards International Field Office No. 33
American Embassy 27 Napier Road Singapore 258508 c/o American Embassy (Mailing Address)
FAA IFO PSC 470, FPO AP 96507-0001
d. Afghanistan, Bangladesh, Bhutan, Brunei, Cambodia, China, Hong Kong, India, Indonesia, Korea, Laos, Malaysia, Maldives, Mongolia, Myanmar, Nepal, Pakistan, Papua New Guinea, Singapore, Solomon Islands, Sri Lanka, Thailand, Tibet, Vietnam Commercial: (65) 545-5822 FAX: (65) 545-9772 Federal Aviation Administration San Francisco International Field Office 831 Mitten Road, Room 105 Burlingame, CA 94010-1303
e. Australia, Cook Islands, Fiji, French Polynesia, Japan, Kiribati, New Caledonia, New Zealand, Philippines, Tahiti, Tonga Islands, Taiwan, Solomon Islands, Vanuatu, Western Samoa and all other territories and international over-water air space described as the Asia-Pacific Area, except for the areas under FSDO and SIN IFO Commercial: (650) 876-2771 FAX: (650) 697-7231
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APPENDIX 3. FAA AIRCRAFT CERTIFICATION OFFICE AND FAA INTERNATIONAL
FLIGHT STANDARDS FIELD OFFICE CONTACTS FOR OTHER COUNTRIES (CONTINUED)
Federal Aviation Administration DFW Flight Standards District Office International Unit P.O. Box 619020 DFW Airport, TX 75261
f. Mexico Federal Aviation Administration (Mailing Address) DFW FSDO-International Unit DFW Business Center, Suite 400 DFW Airport, TX 75261 Commercial: (972) 574-2150 FAX: (972) 574-1699
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APPENDIX 4. ICAO MEMBER STATES
Number of ICAO Member States: 188
*Countries with which the United States has a Bilateral Airworthiness Agreement or a Bilateral Aviation Safety Agreement with Implementation Procedures for Airworthiness.
Afghanistan Albania Algeria Andorra Angola Antigua and Barbuda *Argentina Armenia *Australia *Austria Azerbaijan
Bahamas Bahrain Bangladesh Barbados Belarus *Belgium Belize Benin Bhutan Bolivia Bosnia & Herzegovina Botswana *Brazil Brunei Darussalam Bulgaria Burkina Faso Burundi
Cambodia Cameroon *Canada Cape Verde Central African Republic Chad Chile *China, Peoples Republic of
Columbia Comoros Congo Congo, Democratic Republic of (Zaire) Cook Islands Costa Rica Côte d'Ivoire Croatia Cuba Cyprus *Czech Republic
*Denmark Djibouti Dominican Republic
Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia
Fiji *Finland *France
Gabon Gambia Georgia *Germany Ghana Greece Grenada Guatemala Guinea
Guinea-Bissau Guyana
Haiti Honduras Hungary
Iceland India *Indonesia Iran Iraq Ireland *Israel *Italy
Jamaica *Japan Jordan
Kazakhstan Kenya Kiribati Korea, Democratic People's Republic of (North) Korea, Republic of (South) Kuwait Kyrgyzstan
Laos Latvia Lebanon Lesotho Liberia Libya Lithuania Luxembourg Page 1
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APPENDIX 4. ICAO MEMBER STATES (CONTINUED)
Macedonia Madagascar Malawi *Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Morocco Mozambique Myanmar
Namibia Nauru Nepal *Netherlands Nevis *New Zealand Nicaragua Niger Nigeria *Norway
Oman
Pakistan Palau
Panama Papua New Guinea Paraguay Peru Philippines *Poland Portugal
Qatar
*Romania *Russia Rwanda
Saint Kitts Saint Lucia Saint Vincent and The Grenadines San Marino Sao Tome and Principe Saudi Arabia Senegal Seychelles Sierra Leone *Singapore Slovakia Slovenia Solomon Islands Somalia *South Africa *Spain Sri Lanka Sudan Suriname
Swaziland *Sweden *Switzerland Syria
Tajikistan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan
Uganda Ukraine United Arab Emirates *United Kingdom United States of America Uruguay Uzbekistan
Vanuatu Venezuela Vietnam
Western Samoa
Yemen
Zambia Zimbabwe