Form 8100-13 Organization Designation Authorization Statement of Qual

US Department of Transportation
Federal Aviation Administration

ORGANIZATION DESIGNATION AUTHORIZATION
STATEMENT OF QUALIFICATIONS

OMB Control Number 2120-0704
Expiration Date 08/31/2018

Paperwork Reduction Act Burden 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 2120-0704. Public reporting for this collection of information is estimated to be approximately 5 hours 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 mandatory per 14 CFR Part 183. 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, Federal Aviation Administration, 10101 Hillwood Parkway, Fort Worth, TX
76177-1524

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 (5/12) SUPERSEDES PREVIOUS EDITIONS