Form FAA-5280-1 Application For Certificate

U.S. Department

INFORMATION FOR PUBLIC
RESPONDENT

of Transportation

Federal Aviation
Administration

Application for Certificate
Paperwork Reduction Act Burden 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
2120-0675. Public reporting for this collection of information, including development of an Airport Certification
Manual or Airport Certification Specifications that must accompany this form, is estimated to be approximately 200
hours per response, 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 under 14 CFR Part 139. Send comments regarding this burden estimate or
any other aspect of this collection of information, including suggestions for reducing this burden to the FAA at: 800
Independence Ave. SW, Washington, DC 20591, Attn: Information Collection Clearance Officer, ASP-110.

Form Approved
OMB No. 2120-0675
Exp. 07/31/2015

APPLICATION FOR CERTIFICATE

FAA USE ONLY
Site Number

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)
Original

Amendment

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.

Municipality

State

Military

Corporation

County

Other (Explain)

2. Airport is

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 Signature
Applicant Address/Number/Street/P.O. Box
Applicant Name (typed)

City

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

4. Recommended for
Certificate
Disapproval
5. Remarks

Date
Modification
Letter of Authorization

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

)