8100-13 Organization Designation Authorization Statement of Qual

OMB Control Number 2120-0704
Expiration Date 05/31/2025

U.S. Department
of Transportation

Federal Aviation
Administration

INFORMATION FOR APPLICANT

ORGANIZATION DESIGNATION AUTHORIZATION STATEMENT OF
QUALIFICATIONS
Privacy Act Statement
This statement is provided pursuant to the Privacy Act of 1974, 5 U.S.C. § 552a. The authority for
collecting this information on FAA Form 8100-13, Organization Designation Authorization Statement
of Qualifications is contained in 49 U.S.C. § 44702 as implemented by 14 CFR Part 183. The purpose
of this information is to evaluate an applicant’s application for Organization Designation Authorization
authority. This information is covered by the Privacy Act system of records notice (SORN) DOT/FAA
830, Representatives of the Administrator, and is subject to the following routine uses as published
in the Federal Register: (1) To provide the public with the names and addresses of certain categories
of representatives who may provide service to them; and (2) DOT's Prefatory Statement of General
Routine Uses (available at https://www.transportation.gov/individuals/privacy/privacy-act-systemrecords-notices).. Submission of this data is mandatory and will become part of the Privacy Act
system of records DOT/FAA 830, Representatives of the Administrator. Incomplete submission may
result in delay or denial of your 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 2120-0704. 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

TEAR OFF THIS COVER SHEET BEFORE SUBMITTING THIS FORM

FAA Form 8100-13 (12/24) Supersedes Previous Editions

Electronic Format – PDF

US Department of Transportation
Federal Aviation Administration

ORGANIZATION DESIGNATION AUTHORIZATION
STATEMENT OF QUALIFICATIONS

1. COMPANY NAME:

OMB Control Number 2120-0704
Expiration Date 05/31/2025

2. PHONE NUMBER:

3. COMPANY ADDRESS: (Number, street, city and ZIP code)

4. TYPE OF ODA SOUGHT:
TC

PC

TSO

STC

MRA

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 (12/24) Supersedes Previous Editions

Electronic Format – PDF

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