Domestic TSA Airspace Waiver Applications

--

------■

----tor

■

111:1•

Al.-c:raft 0-r

illilRraft a ....... tor

FilretrcMlddlill Na�
l..alil Name
Olg./Com-nv
Slr'Mt
Ld9'
S�>l'Olllric•
ZllpCoda
,;.,ountry

P1-W

,,,. llr IPl!orM!i
Emall

--

'.
1:DAS

walV111r Sulll)lpe
"1).pllcllUon ID ...

11011912021

waiver Sliilt IOiile
no lmarmatlon provided

nuv.r End Dtna
I
lno .inl'annabon prm,ided
DASl>P lnform.Mloll

o.ft..211,,.._• .., oaa.-- AIM'W"lrt rnro-rmalkNn

Al-,.: Co-de
Fl;w;lld IBIIHd Opwa� {J'BO}
Depal'tl.!,,.D!M!li
Depatllr. 1'11114

1---� •-

ll.l"1"wal 1n1arrn.auon IO DC.A

Oeparu....

O�OCA

kll'TIUUon ll'ol'III CICA

Deparl!Jr. 'T1m11 tram IDCA

Birth
Da'W

Blir:lllo
Pia-

SO<:h
he11rtty

li'11ol CNt.
CountJ)I &
Number

ASO lo.pi'An a
TSA 01"9'1hnti•I

PHM!"IQ� DCA
Dell,'Arr

How la. the •lll'C�aft NCLJred lollO'hell n,ot ope1'8'11onal
..i: � PIie.• Of ot101ri
.,... wfdll gal• Ml!:4!NI, II� gu;ard, .Ci::••

o.oc:Qd n•!'ltM',

- ffi• P4"- Oft .,.,. man19-$1: pot
ft..:I ti.fvt-. bol!rdlnu lltl9 ru•ft?

Afflrimaelon ur1Kh, P«NII/Y'

lltll'

P'lflwy

l. hen by am,
11!Mler �11:y a pem:,i.,,.111at:
The.,� I h!il\'8, provxje;d Oil lfll5 appljoobofl 15 IJua, ocmp1e,1B and =n-BCII to 'lh,e best or my � mlli
ef end IS prl)ICS.IOO may be
pu- by r,ne or ,mpr,s,onme,nt or l:Jelll, iseoa SedJOn 1001 ol' T,
·18 Un,tedl S1afes Code), Bild� be ijlrOUlllds itt decl Iola.-ncl (111',ef'
N
� OI �Of� (HI

UNI'

R

tlon

--

-....:.

..

Contlrma_uon ;S:

Cu1TI1nt L

111:·

,.

11th
li'lin1 Nilft'l4I
Ml.dell• Name
LaatNan•
OrgJCo�
S.11'eet.
City
staltrJ'P\rovlnc•
Zlin COde
Cot.ntry
PihorMI
Z4 hr PIMIIM
Emall

R911u.atcw

-

-.- Su'btyJM
ADDIIOved Distance
APl!lle.Uon Dl!t•

Alr,CAft Op.ir11torr

A.lrerwl't Own.r

I
I

I 10119.iZ0:21

W.IYfl' End O,I ..
I
Ina lnfonna'.lon provided

W.l'l'fl' Start Date
no ln!ormatJon pro•..tded

DCA n onnnon
FRZ lnlonni!! on

Puirpout, of
Fllgh'li'Comm•nta
_______________________________________________
-,.-Al�r-c_ll'._-i:!_1'1:

I

Alrcnift

Birth
l!)-.t.

Birth
PJ-

lw- •re UNI, pen10na an 1he manifeat pc141I
lkHntffl-«1 llefon boarding 11'19 1111rc.-aft?

I

Provide .addltlanal seeul'lly meall.'llre& taken,

Saclam
.S.Cunty

ely

P-•■apolit Counb)! & PilliM Cert Coun-uy &
11mbff
mbH

ASO Dept.Airr & TSA
CN,chntillll

I
I
I

I

r ani�

.A'fillrr.natlon !lllllllflr IJM!l'tally .o1l pe;rJul!Y
1. Mr-eb,y • - ""'' of
--'----�•-_J on ti
"°" IS lrlN. comi::,
W'ld «u-r t IO tne,
tor ffiJ' 1<�
t 8J"ld is i:,ro,,,,dod
TIie ,�,on I
J11 good farlh. I
kn:JwD,;j and vn ul 1e1s.e Sla':emenl, Of an omtSSMlCfl of :ai lllli!lte J ract on his applcsbcft ITli3Y be
ion 1001 or T,1 UJ. U\n,1
s
COde). md moy
gc� ror den I or ,,.
11)1.1
b'f i,
01
�
raQuest or suspension Of re-.oca'IMlll
and Olil8r ll'8Bill es.

AOC l)'tedl
• Do,;.uments

uU'a•rr

l

Load Date,

IAll'eolft OoiiH1tor

TJ1lt,
Fh1N■rne
Mlddfe Name

Alrer-aftO--I

Last Name

Ofa.lCompany
heM

CflY
StataJProvlnc:e
£ID Code
Country
P,hcm,,a
:M hr Phone
Eimall

-'

'-.�

IIIWVfl SLflblW)e
FDgM fype
:A-'leatlon Date

10,18/2021

WIiiiver Slut EMie

no lnfonnatlon

�P■ml"'1 PolnU•I
ln18nnedlllbl St01141■I
0.a1inatlon Point
Final De■llnaUonCa,

Waiver End Date
I
lno 1ntormat10n provided

11111-no

-

-

CNIIIIUl1:HIII CO.,g,ct lnl!tHm::i.tlon

Narn,e,
S1r>Nt
City
S't!luu.-..... ,nQII<
Countrv

�coo.
Phone

I

Pul')IOM 01'
I:Fligllti'Commenta

I
C■IIS:l;n

FUii
�nele
MMne

"" Sc,,;:urnty St:.,f.ernr.,nt

All'Cl"aftlype

Birth
Olla

SOCIII
Security

Regllatratlon

Gron W..liljlhi

P111,portcoumry a Pil�C rt. COilntlY a· ASO DfP/Aff a TI1A I
Number
Number
Creden I

How 1, tl"le ,1rcratt Mcure.ii Wh n r.ot opeq1Mtn,1
· the place ot od;in? (Locked hangar,
-rM wttl'I Gate uc.u, w,cwtty gua,-,d, �)

How ■re, 1he pe,aCIRII. on die IIYnffnt poalll,vet¥
ldtntfflitd btfOM bolrdln:g U. llrcral't?

Provide addlillonall McUJilty na._su� tallen, tf ■n¥.1

Afflnn;1Clon und.-r pen 'lty •11 p,9rjury

1, l"!effbY · ·1mm,
TI'!O 1iUornwrt,on I
1n 9(l(ld r.ir111 1 u
pta1isl'-1 by fi'

�

�

. « _
on 1M
a, llOWI
cx bCllh (sae

«Id I Pl'
is troo � •
o00i
110 In bes.I or my lFile Typeapplication/pdfFile Modified2022-01-21File Created2022-01-21