Date: ***
Dennis S. Carley
P.O. Box 3649
DeLand, FL 32721
In accordance with section 21.193, I request a Special Airworthiness Certificate for my aircraft for the purpose of operating light sport aircraft. The Aircraft description is as follows:
Builder: Registration No.:
Serial No: Model:
Engine: Seats:
The aircraft is complete and the following items have been accomplished:
1. I enclose FAA Form 8130-6 (Application for Airworthiness Certificate) with Sections I, II and III complete.
2. I posses AC Form 8050-3 (Aircraft Registration Certificate).
3. I enclose 3 view drawings or photographs of the aircraft.
4. I have weighed the aircraft to determine that the most forward and aft center of gravity positions are within established limits. The weight and balance report is available at the aircraft, and a copy is submitted with this application.
5. I do / do not intend to use this aircraft for compensation to conduct flight training.
6. I do / do not intend to use this aircraft for compensation to tow a light sport glider or ultralight.
7. The marking requirements of Part 45 have been complied with, including permanent attachment of a fireproof identification (data) plate, permanent application of appropriate registration marks, and the word “Experimental” displayed near each entrance to the cockpit.
8. The following placard is displayed in the cockpit in full view of all occupants: “Passenger notice – This aircraft is an experimental light sport aircraft and does not comply with the federal safety regulations for standard aircraft.”
The aircraft is available for inspection at ****.
I request airworthiness certification and operating limitations be issued permitting me to operate the aircraft within the following geographical area for flight testing:
*****
Name
Phone Numbers:
Email Address: