Form 7711-2 Certification of Waiver or Authorization Application

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BEFORE USING

DEPARTMENT OF TRANSPORTATION
FEDERAL AVIATION ADMINISTRATION

SUPPLEMENTAL
INFORMATION

CERTIFICATION OF WAIVER OR AUTHORIZATION APPLICATION

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 currently valid OMB Control Number. The OMB
Control Number for this information collection is 2120-0027. Public reporting for this collection of information is estimated to be approximately 45 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, completing and reviewing the collection of information. All responses to this collection of
information are required to obtain or retain a benefit by 14 CFR Part 91, Part 101, and Part 105. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden to the FAA at: 800 Independence Ave. SW, Washington, DC 20591, Attn: Information Collection Clearance Officer, AES-200.

FAA Form 7711-2 (6-86) Supersedes Previous Edition
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No certificate may be issued unless a completed application
form has been received (14 C.F.R. 91, 101, and 105).

Form Approved: O.M.B. No. 2120-0027 08/31/2008

US Department of Transportation

APPLICANTS - DO NOT USE THESE SPACES
Region

Federal Aviation Administration

Date

Action

APPLICATION FOR
CERTIFICATE OF WAIVER
OR AUTHORIZATION

Approved

Disapproved - Explain under "Remarks"

Signature of authorized FAA representative

INSTRUCTIONS
Submit this application in triplicate (3) to any FAA Flight
Standards district office.
Applicants requesting a Certificate of Waiver or Authorization for an aviation event must complete all the applicable
items on this form and attach a properly marked 7.5 series
Topographic Quadrangle Map(s), published by the U.S.
Geological Survey (scale 1:24,000), of the proposed operating area. The map(s) must include scale depictions of the
flightlines, showlines, race courses, and the location of the
air event control point, Police dispatch, ambulance, and fire
1. Name of organization

3. Permanent
mailing

address

fighting equipment. The applicant may also wish to submit
photographs and scale diagrams as supplemental material
to assist in the FAA's evaluation of a particular site.
Application for a Certificate of Waiver or Authorization must
be submit- ted 45 days prior to the requested date of the
event.
Applicants requesting a Certificate of Waiver or Authoriza­
tion for activities other than an aviation event will complete
items 1 through 8 only and the certification, item 15, on the
reverse.
2. Name of responsible person

House number and street or route number

City

State and ZIP code

Telephone No.

4. FAR section and number to be waived

5. Detailed description of proposed operation (Attach supplement if needed)

6. Area of operation (Location, altitudes, etc.)

7a. Beginning (Date and hour)

8.

Aircraft
make and model
(a)

b. Ending (Date and hour)

Pilot's Name
(b)

FAA Form 7711-2 (6-86) Supersedes Previous Edition

Certificate number
and rating
(c)

Home address
(Street, City, State)
(d)

ITEMS 9 THROUGH 14 TO BE FILLED OUT FOR AIR SHOW/AIR RACE WAIVER REQUESTS ONLY.
9. The air event will be sponsored by:

10. Permanent
mailing
address

House number and street or route number

City

State and ZIP code

Telephone No.

11. Policing (Describe provisions to be made for policing the event.)

12. Emergency facilities (Mark all that will be available at time and place of air event.)

Physician

Fire truck

Ambulance

Crash wagon

Other - Specify

13. Air Traffic control (Describe method of controlling traffic, including provision for arrival and departure of scheduled aircraft.)

14. Schedule of Events (include arrival and departure of scheduled aircraft and other periods the airport may be open.)
Hour
(a)

Date
(b)

Event
(c)

If sufficient space is not available, the entire schedule of events may be submitted on separate sheets, in the order and manner indicated above.

Please Read

The undersigned applicant accepts full responsibility for the strict observance of the terms of the Certificate
of Waiver or Authorization, and understands that the authorization contained in such certificate will be strictly
limited to the above described operation.

15. Certification - I CERTIFY that the foregoing statements are true.

Date

Signature of Applicant

Remarks

FAA Form 7711-2 (6-86) Supersedes Previous Edition