Form 4540 Foreign Air Carriers Application for Statement of Author

The information collected by this form is used by foreign air carriers to apply affirmatively for statements of authorization under 14 CFR Part 212 to conduct third- and fourth-freedom charter operations that require prior approval, long-term wet-leases, and fifth-freedom charter operations. A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number.  The OMB Control Number for this information collection is 2106-0035, and the expiration date is MM/DD/YYYY.  Public reporting for this collection of information is estimated to be approximately 30 minutes per response, including the time for reviewing instructions, completing and reviewing the collection of information.  All responses to this collection of information are mandatory.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to:  Information Collection Clearance Officer, (U.S. Department of Transportation, Office of International Aviation (X-40), 1200 New Jersey Avenue, SE, Suite W86-125), Washington, D.C. 20590.
U.S. Department of Transportation FOREIGN AIR CARRIER APPLICATION FOR STATEMENT OF AUTHORIZATION (See Instructions on Reverse Side)			DO NOT WRITE--FOR OFFICIAL USE ONLY _____________________________________________________ Disposition of Application: __ Approved __ Approved, subject to condition(s) on reverse __ Disapproved/Dismissed for reason(s) cited on reverse. Under assigned authority _______________________ Effective from _______________ to ______________ Director, Office of International Aviation
To: Department of Transportation Foreign Air Carrier Licensing Division, X-45 Office of International Aviation 400 Seventh Street, S.W. Washington, D.C. 20590			Operations pursuant to this authorization shall conform to Part 212 of the Department’s regulations, to the terms, conditions and limitations of the applicant’s foreign air carrier permit or exemption, and to Part 129 of the Federal Aviation Regulations.
Application is made for authorization to conduct charter flights under provisions of applicant’s foreign air carrier permit and 14 CFR 212 or DOT order.
1. Name of Applicant: Nationality: _________________________________________________ 2. Send authorization To: a. Name and Address: b. Telephone: Fax:		3. Name of Charterer: Address: _________________________________________________ 4. Total charter price:
5. Dates of flights under this authorization:
6. Aircraft make, model, and capacity:	7. Country in which aircraft is registered:
8. Planned routing of flights (indicate non-traffic stops by asterisks):
9. No. of flights _____________________________________ (specify whether one-way or round-trip) and type: Passenger ___ Cargo ___ Mixed ___ For passenger flights: available passenger seats _____, number of passengers to be carried _____. If cargo to be carried, weight and description of cargo:

OST Form 4540 (Continue on back)

10. If application is being filed late, state reason for lateness:

11. Description of chartering organization and purpose of flights:

12. Does the nation which is the domicile of the applicant grant to United States carriers a privilege similar to that requested

herein? _____; if so, has evidence of such reciprocity, from an official of the carrier’s homeland government, been submitted to the Department? ______; when?_____________. Date that applicant last verified reciprocity____________(must be in preceding six months); with whom?_________________. If the fact has not been established with the Department, provide documentation to establish such reciprocity.

13. Other information requested by DOT (other than third- and fourth-freedom applications): Include here the number of one-way third- and fourth-freedom flights operated by the applicant in the preceding 12 month period/calendar year (alternatively, this information may be provided in a cover letter).

CERTIFICATION

I hereby certify that the flights for which authority is sought herein conform to the requirements of DOT’s Regulations and applicable orders of DOT governing charters.

________________________ __________________________________________________

(Date) (Signature and title of authorized officer)

INSTRUCTIONS

1. Prepare an original and one copy of this application according to Section 212.10 of the Department’s Regulations.

If extra space is required to complete an item, continue on a separate sheet of paper.

2. Send the application to: Department of Transportation, Foreign Air Carrier Licensing Division, X-45, Office of International Aviation, 1200 New Jersey Avenue, S.E., Washington, D.C. 20590 (and, if required by regulation or Order, to the Director of Flight Standards Service (AFS-1), Federal Aviation Administration, 800 Independence Avenue, S.W.,

Washington, D.C. 20591).

DO NOT WRITE -- FOR OFFICIAL USE ONLY

Exercise of the authorization is subject to the following condition(s), OR Application is disapproved/dismissed for the following reason(s):