4540 Foreign Air Carriers Application for Statement of Author

OMB Control No.: 2106-0035
Expiration Date: MM/DD/YYYY
The information collected by this form is used by foreign air carriers to apply affirmatively for statements of authorization under 14 CFR Part 212 to conduct
third- and fourth-freedom charter operations that require prior approval, long-term wet-leases, and fifth-freedom charter operations. 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 2106-0035. Public reporting for this collection of information is estimated to take approximately 2.25 hours
per response, including approximately 30 minutes for reading the instructions, and completing and reviewing the form and an additional 1.75 hours for
compiling background information associated with the collection of information. All responses to this collection of information are mandatory. 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, U.S. Department of Transportation, Office of International Aviation (X-40), 1200 New Jersey Avenue, SE, Suite W86-125,
Washington, DC 20590.
DO NOT WRITE--FOR OFFICIAL USE ONLY
_____________________________________________________

Disposition of Application:

__ Approved
__ Approved, subject to condition(s) on
reverse
__ Disapproved/Dismissed for reason(s)
cited on reverse.

U.S. Department of
Transportation

FOREIGN AIR CARRIER APPLICATION FOR
STATEMENT OF AUTHORIZATION

Under assigned authority _______________________
Effective from _______________ to ______________

(See Instructions on Reverse Side)

Director, Office of International Aviation
To: U.S. Department of Transportation
Operations pursuant to this authorization shall conform
Foreign Air Carrier Licensing Division, X-45
to Part 212 of the Department’s regulations, to the
Office of International Aviation
terms, conditions and limitations of the applicant’s
1200 New Jersey Avenue, SE
foreign air carrier permit or exemption, and to Part 129
Washington, DC 20590
of the Federal Aviation Regulations.
Application is made for authorization to conduct charter flights under provisions of applicant’s foreign air carrier permit and
14 CFR 212 or DOT order.
1. Name of Applicant:
3. Name of Charterer:
Nationality:
_________________________________________________
2. Send authorization To:
a. Name and Address:

Address:

_________________________________________________
4. Total charter price:

b. Telephone:
Fax:
5. Dates of flights under this authorization:
6. Aircraft make, model, and capacity:

7. Country in which aircraft is registered:

8. Planned routing of flights (indicate non-traffic stops by asterisks):

9. No. of flights _____________________________________ (specify whether one-way or round-trip) and type:
Passenger ___

Cargo ___

Mixed ___

For passenger flights: available passenger seats _____, number of passengers to be carried _____.
If cargo to be carried, weight and description of cargo:
OST Form 4540

(Continue on back)

OMB Control No.: 2106-0035
Expiration Date: MM/DD/YYYY

10. If application is being filed late, state reason for lateness:

11. Description of chartering organization and purpose of flights:

12. Does the nation which is the domicile of the applicant grant to United States carriers a privilege similar to that requested
Yes
herein? _____;
if so, has evidence of such reciprocity, from an official of the carrier’s homeland government, been submitted
Yes
to the Department? ______;
when?_____________. Date that applicant last verified reciprocity____________(must be in
preceding six months); with whom?_________________. If the fact has not been established with the Department, provide
documentation to establish such reciprocity.
13. Other information requested by DOT (other than third- and fourth-freedom applications): Include here the number of oneway third- and fourth-freedom flights operated by the applicant in the preceding 12 month period/calendar year (alternatively,
this information may be provided in a cover letter).

CERTIFICATION
I hereby certify that the flights for which authority is sought herein conform to the requirements of DOT’s Regulations and
applicable orders of DOT governing charters.
________________________
(Date)

__________________________________________________
(Signature and title of authorized officer)
INSTRUCTIONS

1. Prepare an original and one copy of this application according to Section 212.10 of the Department’s Regulations.
If extra space is required to complete an item, continue on a separate sheet of paper.
2. Send the application to: Department of Transportation, Foreign Air Carrier Licensing Division, X-45, Office of
International Aviation, 1200 New Jersey Avenue, SE, Washington, DC 20590 (and, if required by regulation or Order, to the
Director of Flight Standards Service (AFS-1), Federal Aviation Administration, 800 Independence Avenue, SW,
Washington, DC 20591).
DO NOT WRITE -- FOR OFFICIAL USE ONLY
Exercise of the authorization is subject to the following condition(s), OR Application is disapproved/dismissed for the
following reason(s):