Form 4532 STATEMENT OF CHARTER OPERATOR AND DIRECT AIR CARRIER

OMB No. 2106-0005
Expires 09/30/2012

PAPERWORK REDUCTION Act Statement
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 Control Number for this information
collection is. 2106-0005. 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 voluntary.
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-46, 1200 New Jersey Avenue SE,
Suite W-86-445, Washington, DC 20590.

For DOT Use Only –PC No. ______________ Waiver No. ____________
STATEMENT OF CHARTER OPERATOR AND DIRECT AIR CARRIER
FLIGHT SCHEDULE NUMBER ___________________

U.S. Department of
Transportation
Office of the Secretary
of Transportation

INSTRUCTIONS: Date of filing for purposes of DOT regulations is the date properly completed forms are received by DOT.
1a. Name (and DBA, if applicable) and Mailing Address of Charter Operator

1b. Telephone Number (
Fax Number

(

) ___________________________
) ___________________________

2a. Name (and DBA, if applicable) and Mailing Address of Direct Air Carrier:

2b. Telephone Number (
Fax Number

(

) ____________________________
) ____________________________

3. Proposed date and routing of each flight: (use additional pages, if necessary)

4. Type of aircraft and number of seats engaged:

5. Charter price of each flight:*
$_____________________
6. Tour itinerary (if any) including hotels (names and length of stay at each), and other accommodations and services:

*If confidentiality is desired, please state charter price in separate correspondence.
OST Form 4532

OST 4530, 32-35 Form Disk

We, _______________________________________________________________________________________________________
(Charter Operator)

and ________________________________________________________________________________________________________________
(Direct Air Carrier)

certify that we have entered into a charter contract on ____________________________________________________________ that covers the
(Date)

flight schedule described above. The contract complies with all applicable DOT regulations.

7. A copy of the flight schedule has been sent to (complete applicable blanks and write “N.A.” in those not applicable):

_______________________________________________________________________________________________________________
(Charter Operator’s Securer)

_______________________________________________________________________________________________________________
(Charter Operator’s Depository Bank)

_______________________________________________________________________________________________________________
(Direct Carrier’s Securer)

_______________________________________________________________________________________________________________
(Direct Carrier’s Depository Bank)

8. Applicant is a U.S. Public Charter Operator as defined in Section 380.2 of the Department’s regulations:

________________________________________

_________________________________________

(Signature of Officer)

(Title)

CHARTER OPERATOR

9.

BY:

______________________________

(Name in print)

DIRECT AIR CARRIER

______________________________________________

BY:

_____________________________________________

(Signature)

(Signature)

______________________________________________

_____________________________________________

(Name in print)

(Name in print)

______________________________________________

_____________________________________________

(Title)

(Title)

_______________________/_______________________
(Phone Number)

(Fax Number)

______________________________________________
(Street, Box Number)

______________________________________________
(City, State, Zip Code)

______________________________________________
(Date)**

**This document is not acceptable if not dated.

______________________/_______________________
(Phone Number)

(Fax Number)

______________________________________________
(Street, Box Number)

______________________________________________
(City, State, Zip Code)

______________________________________________
(Date)**