Form 8100-13 Organization Designation Authorization Statement of Qual

OMB Control Number 2120-0704
Expiration Date 04/30/2022

U.S. Department
of Transportation
Federal Aviation
Administration

INFORMATION FOR APPLICANT

ORGANIZATION DESIGNATION AUTHORIZATION STATEMENT OF
QUALIFICATIONS
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 2120-0704. Public reporting for this collection of information is estimated to be approximately
5 hours per new application, 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
Privacy Act Statement
Privacy Act Statement (5 U.S.C. § 552a(e)(3)):
Authority: Information on FAA Form 8110-14, Statement of Qualifications, is solicited under the
authority of Title 14 of Code of Federal Regulations, Part 183.
Purpose: The purpose of collecting this information is to evaluate an application, to establish an
applicant’s qualifications as a designee and to determine the applicant’s eligibility for the
designation sought.
Routine Uses: In accordance with the Privacy Act system of records DOT/FAA 830,
Representatives of the Administrator, this information is routinely used to provide the public with
the names and addresses of certain categories of representatives who may provide service to
them. The Department has also published 15 additional routine uses applicable to all DOT Privacy
Act systems of records. These routine uses are published in the Federal Register at 84 FR 55222 October 15, 2019 and 77 FR 42796 - July 20, 2012, and under ‘‘Prefatory Statement of General
Routine Uses’’ (available at http://www.transportation.gov/privacy/privacyactnotices).
Disclosure: Submission of the data is voluntary and will become part of Privacy Act System of
Records DOT/FAA 830 Representatives of the Administrator. Incomplete submission may result in
delay or denial of your request.

TEAR OFF THIS COVER SHEET BEFORE SUBMITTING THIS FORM

FAA Form 8100-13 (09-2018) Supersedes Previous Editions Electronic Format – PDF

US Department of Transportation

ORGANIZATION DESIGNATION AUTHORIZATION
STATEMENT OF QUALIFICATIONS

OMB Control Number 2120-0704
Expiration Date 04/30/2022

Federal Aviation Administration

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

AO

PMA

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 (09-2018) Supersedes Previous Editions Electronic Format – PDF

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