Form FAA-5280-1 Application For Certificate

Form Approved OMB No. 2120-0675

FAA USE ONLY
Site Number

APPLICATION FOR CERTIFICATE

Department of Transportation
Airport Operating Certificate
Time-Limited Airport Operating Certificate
Federal Aviation Administration
Complete all sections of the form as indicated. Submit original and three copies of the form and two copies of the Airport Certification Manual
to the headquarters of the appropriate FAA Regional Office.
Type of Submission (Check One)
Amendment

Original

Exemption

A. Location of Airport
1. Name of Airport

2. Address (Number, Street, P.O. Box)

3. City

4. County

6a. Latitude

6b. Longitude

°

'

°

"

'

5. State

Airport is:
a. State Licensed
b. State Inspected

"

Yes
Yes

6. Zip Code

No
No

B. Ownership
1.

2. Airport is

Municipality

State

Military

Corporation

County

Other (Explain)

Port Authority

Airport Authority

Mil/Civ Joint Use
Shared Use

3. Name of Owner

4. Name of Manager/Operator

Number/Street/P.O. Box
City

Civil

County

Number/Street/P.O. Box
State

Zip

City

County

State

Zip

C. Operative Data
1. Certificate Applied For:
Class I

Class II

Class III

Class IV

2. Fire Fighting Equipment (Check Current Index and ensure
equipment is listed in ACM)
A

B

C

D

E

3. Air Carriers to be served (UA, DL, CO, AA, etc.)

4. Air Carrier Aircraft to be served (737, DC-9, A-320, etc.)

5. ARFF Exemption Applied For:

6. Other exemptions applied for:

Yes
D. Remarks

No
Check here and use additional sheet of paper.

E. Certification
This application, including the Airport Certification Manual, is submitted in order to obtain an Airport Operating Certificate or Time-Limited
Airport Operating Certificate. I certify, under penalty of 18 U.S. Code, Section 1001, and other applicable provisions of law that the statements
and information in the application form and manual are complete and true to the best of my knowledge.
Applicant Address/Number/Street/P.O. Box
Applicant Signature
City

Applicant Name (typed)
Applicant Title

Date Submitted

State

Zip

Telephone No.
(

FAA Use Only
1. Date Application received

2. Date Proposed for Inspection

3. Date Inspection Completed

Signature

Title

Signature

Title

Date

4. Recommended for
Certificate
Disapproval
5. Remarks

Modification
Letter of Authorization

FAA 5280-1 (2-04) Supersedes Previous Edition

)

Paperwork Reduction Act Statement
The information collected on this form is necessary to determine applicant eligibility for airport operating certificates.
The FAA estimates that it will take 200 hours to complete this form and develop an Airport Certification Manual or
Airport Certification Specifications that must accompany this form. This collection of information is mandatory under
14 CFR Part 139. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid OMB control number. The control number for this collection of
information is 2120-0675.