Form 8100-13 Organization Designation Authorization Statement of Qual

Organization Designation Authorization STATEMENT OF QUALIFICATIONS

OMB Control Number 2120-0704 Expiration Date 01/31/2012

US Department of Transportation Federal Aviation Administration

Paperwork Reduction Act Statement: This collection of information is to obtain information concerning the applicant's qualifications. The FAA uses the information provided to determine the suitability of the applicant to act as a representative of the administrator for the purpose of issuing FAA design and airworthiness approvals. The burden associated with new applications using this form is 5 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 control number. The OMB control number for this form is 2120-0704. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden to the FAA at: 800 Independence Ave. SW Washington DC, 20591, attn: Information Collection Clearance Officer, AES-200

1. COMPANY NAME:

2. PHONE NUMBER:

3. COMPANY ADDRESS: (Number, street, city and ZIP code)

4. TYPE OF ODA SOUGHT:

TC

PC

TSO

STC

MRA

PMA

AKT

AO

Other

5. FUNCTIONS SOUGHT: (Applicants shall identify below the specific function(s) 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 TYPE OF ODA SOUGHT:

Certificate 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

Signature (Management representative of company requesting delegation)

FAA Form 8100-13 (12-09)