Form 8710-3 Agricultural Aircraft Operator Certificate Application

AGRICULTURAL AIRCRAFT OPERATOR CERTIFICATE APPLICATION
US Department
of Transportation
Federal Aviation
Administration

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 current valid OMB Control Number. The OMB Control Number for this
information collection is 2120-0049. Public reporting for this collection of information is estimated to be approximately 1 hour per
response, including the time for reviewing instructions, completing and reviewing the collection of information. All responses to this
collection of information are mandatory per 14 CFR Part 137. Comments concerning the accuracy of this burden and suggestions for
reducing
the burden should be directed to the FAA at: 800 Independence Ave. SW, Washington, DC 20591, Attn: Information Collection
�
Clearance Officer, ASP-110.

SUPPLEMENTAL

TEAR OFF
BEFORE USE
Form 8710-3 (10-83)

INFORMATION
DETACH THIS PART BEFORE USING FORM BELOW

Form Approved
OMB No. 2120-0049
([S0/31/20

INSTRUCTIONS
Submit in duplicate to the local

General Aviation District Office.

AGRICULTURAL AIRCRAFT OPERATOR
CERTIFICATE APPLICATION

US Department
of Transportation
Federal Aviation

Administration

TYPE

1. APPLICATION
FOR

FOR DISPENSING (Check one)
ECONOMIC POISONS

AMENDMENT

COMMERCIAL

OTHER THAN ECONOMIC POISONS

REISSUANCE

2. NAME AND ADDRESS OF APPLICANT

3. PRINCIPAL OPERTIONS BASE (Airport, City, State)

TELEPHONE NUMBER

TELEPHONE NUMBER
INDIVIDUAL

2. OPERATING
AS

OTHER (Specify)

5. NAME OF CHIEF SUPERVISOR OF OPERATIONS IF OTHER
THAN SHOWN IN ITEM 2. (COMMERCIAL OPERATIONS ONLY)

CORPORATION
PARTNERSHIP

(First)

6. AIRMAN CERTIFICATE HELD

(Middle Initial)
CERTIFICATE NUMBER

TYPE RATING(S) (Specify)

ASEL

AMES

COMMERCIAL

AMEL

HELICOPTER

AIRLINE TRANSPORT

ASES

GYROPLANE

NO

YES (Complete 7B)

DO YOU HOLD A CURRENTLY EFFECTIVE CERTIFICATE OF WAIVER FOR
CONDUCTING AGRICULTURAL AIRCRAFT OPERATIONS?

7B. WAIVER HELD

(Last)

RATINGS

GRADE

PRIVATE

7A.

ORIGINAL

PRIVATE

DATE ISSUED

EXPIRATION DATE

FAA DISTRICT OFFICE WHERE ISSUED

8. AGRICULTURAL AIRCRAFT TO BE OPERATED
MAKE

EQUIPPED FOR

MODEL

LIQUID

SOLID

TOTAL NUMBER EACH
AIRCRAFT OPERATED

REGISTRATION MARK
(List one)

9. LIST THE NAME(S) AND AIRMAN CERTIFICATE NUMBER OF AGRICULTURAL PILOT(S) WORKING FOR YOU AT THE PRESENT TIME
(Use separate sheet and attach if additional space is needed.)
NAME

CERT. NO.

NAME

10. REMARKS

11. CERTIFICATION: I CERTIFY THAT STATEMENTS MADE ON THIS FORM ARE TRUE AND CORRECT.
DATE

FAA Form 8710-3

TITLE

(10-83)

SIGNATURE

CERT. NO.

INSPECTION REPORT - For FAA Use Only
(To be completed by the General Aviation for Flight Standards District Office)
COMPLIANCE WITH APPLICABLE REGULATIONS
1. PILOTS

NOT REQUIRED

SATISFACTORY

A. CERTIFICATES
B. RATING(S)
C. KNOWLEDGE TEST
D. SKILL TEST
2. AIRCRAFT
A. CERTIFICATED
B. AIRWORTHY
C. EQUIPPED FOR AGRICULTURAL OPERATIONS
10. REMARKS (Include an explanation of denial if application is disapproved).

4. DISTRICT OFFICE ACTION
CERTIFICATE ISSUED
APPLICATION DISAPPROVED
DATE INSPECTION COMPLETED

INSPECTORS SIGNATURES

UNSATISFACTORY