Form FAA-8110-12 Application for Type Certificate, Production Certificate

INFORMATION FOR APPLICANT
U.S. Department
of Transportation

Federal Aviation
Administration

APPLICATION FOR TYPE CERTIFICATE, PRODUCTION CERTIFICATE,
OR SUPPLEMENTAL TYPE CERTIFICATE
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 collection of
information displays a current valid OMB Control Number. The OMB Control Number for this
information collection is 2120-0018. Public reporting for this collection of information is
estimated to be approximately 48 minutes per response, including the time for reviewing
instructions, completing and reviewing the collection of information. All responses to this
collection of information are required to obtain or retain benefits under the authority of 49
U.S.C. 44702 as implemented by 14 CFR Part 21.
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, ASP-110.

Tear off this cover sheet before submitting this form.

FAA Form 8110-12 (4-03) Supersedes Previous Edition

86 DEPARTMENT OF TRANSPORTATION
FEDERAL AVIATION ADMINISTRATION

FORM APPROVED
O.M.B. No. 2120-0018
04/30/2015

APPLICATION FOR TYPE CERTIFICATE, PRODUCTION

CERTIFICATE, OR SUPPLEMENTAL TYPE CERTIFICATE

2. Application made for:

1. Name and address of applicant:

3. Product Involved :
Aircraft

Type Certificate
Production Certificate

Engine
Propeller

Supplemental Type Certificate
4. TYPE CERTIFICATE (Complete item 4a below)

a. Model designation (s) (All models listed are to be completely described in the required technical data, including drawings representing the
design, material, specifications, construction, and performance of the aircraft, aircraft engine, propeller which is the subject of this application.)

5. PRODUCTION CERTIFICATE: (Complete items 5a-c below. Submit with this form, in manual form, one copy of quality control data or
changes thereto coveting new products, as required by applicable FAR.)
a. Factory address: (if different from above)

b. Application is for:

P.C. No.

New production certificate
Additions to production
Certificate (Give P.C. No.)

c. Applicant is holder of or a licensee under a Type Certificate or a Supplemental Type Certificate:

T.C./S.T.C. No.

(Attach evidence of licensing agreement and give certificate number)

6. SUPPLEMENTAL TYPE CERTIFICATE: (Complete items 6a-d below)
a. Make and model designation of product to be modified:

b. Description of modification:

c. Will data be available for sale or release to other persons ?
Yes

d. Will parts be manufactured for sale? (Ref. FAR 21.303)

No

Yes

No

7. CERTIFICATION - I certify that the above statements are true.
Signature of Certifying Official

FAA Form 8110-12 (4-03) Supersedes Previous Edition

Title

Date