Form 2120-0652 Special Flight Authorization (Noise)

Federal Aviation Administration

Special Flight Authorization (Noise)

For Stage 2 Airplanes Over 75,000 Pounds

OMB Approval No. 2120-0652

Exp. 7/31/2009

1. Applying Operator

1. Operator’s Name:

2. Address:

3. City:

4. State and Zip Code:

5. Country:

Contact

6. Name:

7. Phone Number:

8. Fax Number:

9. Email Address:

2. Airplane

1. Make, Model, and Series:

2. Registration Number:

Country of Registration (if not U.S. registered):

3. Serial Number:

4. Current Noise Certification (check one):

□ Stage 1 □ Stage 2

3. Purpose (Check one and give name and address below):

Name:

Address:

□ a) Sell, lease or use the airplane outside the contiguous 48 States.

□ b) Scrap the airplane.

□ c) Modify the airplane to meet Stage 3 noise levels.

□ d) Perform scheduled heavy maintenance or significant modifications on the airplane at a maintenance facility in the contiguous 48 States. Maintenance (Check all that apply):

□ “C” Check □ “D” Check

□ Other significant modifications (describe):

□ e) Deliver the airplane to a lessee. (Include name and address below):

Name:

Address:

□ f) Return the airplane to the lessor. (Include name and address below):

Name:

Address:

□ g) Prepare, park or store the airplane in anticipation of any of the activities described in (a) through (f). (Include name and address of storage or maintenance facility below):

Name:

Address:

4. Flights Dates (approximate start and end dates). Use mm/dd/yy:

Flight 1:

Flight 2:

Flight _____:

5. Number of persons on board (up to 5 total).

____ Pilots ____ Officers

____ Flight Engineers ____ Maintenance/Tech Representatives

Fax This Form

Attention: Special Flight Authorization (Noise)

Fax number: (202) 267-5594

Questions about this form?

Please call (202) 267-3577

Note: This form is an application for a special flight authorization only. It may not be used to fly an airplane. It must be submitted to the FAA, which will issue a special flight authorization based on the information provided above.

When issued, the Special Flight Authorization must be carried on board the airplane during the authorized flight. Persons on board are limited to flight crew only. A Special Flight Authorization issued pursuant to this application is for noise only and my not be used as a substitute for other ferry permit or authorization that may be required for airworthiness or other purposes, such as 14 CFR 21.199, Issue of special flight permits or 43.3, Persons authorized to perform maintenance, preventative maintenance, rebuilding, and alterations.

Paperwork Reduction Act Statement

The information collected on this form is required by PL 106-113. The FAA will use the information to issue special flight authorizations for non-revenue operations of Stage 2 airplanes at U.S. airports. The annual burden is estimated to be 25 hours based on 100 requests at 15 minutes per request. The submission of information is voluntary.

If proprietary information is submitted, it will be protected in accordance with appropriate laws. 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 for this collection is 2120-0652. 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, AES-200.