Form Av-3 - Application For Airport/heliport License Renewal
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1
2ApplicAtion for Airport/heliport
AV-3 (10-15)
license renewAl
www penndot gov
renewAl fee: $75 - 3 YeAr license
APPLICANT INFORMATION
i/we hereby make application for renewal of the license to operate the below listed private Airport/heliport and affirm that i am (we are) the
owner(s)
lessee(s) of the property.
Airport/heliport name:
Date
fAA iD
name of licensee
point of contact (if different than licensee)/or Additional licensee
Daytime phone number
email Address
Daytime phone number
email Address
Mailing Address (street/po Box)
Mailing Address (street/po Box)
city
state
Zip code
city
state
Zip code
AIRPORT/HELIPORT INFORMATION
physical Address of Airport/heliport (street/rr/sr)
township/Borough
state
Zip code
county
Airport
heliport
runway length: _______________ ft.
width: ______________ ft.
Diameter/Dimensions of landing Area: ______________ ft _____________ ft
runway Magnetic headings: _______________ / ________________
primary Appr/Dep headings: _______________ / _______________
type runway:
paved
turf
secondary Appr/Dep headings: _______________ / _______________
is the runway lighted?
Yes
no
is heliport lighted?
Yes
no
Are commercial activities planned for or occurring at this facility?
Yes
no
[Maintenance, flight instruction, fueling]
were any significant changes made to the facility since last inspection?
Yes
no if yes, please describe:
list All BAseD AircrAft (Attach Additional Sheets if Necessary)
MAnUfActUrer
MoDel
reGistrAtion #
owner
CERTIFICATION
i hereby certify that i am the owner, or authorized agent, of the above named airport/heliport, that the information contained herein is true
and correct, and that i am familiar with the commonwealth of pennsylvania regulations governing licensing and operation of private
Airports and/or heliports.
Name (Print)
Signature
Date (mm/dd/yyyy)
Title
complete and mail to:
pennDot Bureau of Aviation
for BUreAU of AviAtion onlY
Attn: licensing coordinator
license fee pAiD $___________ lic#______________
p.o. Box 3151
initiAl _______________ DAte _______________
harrisburg, pA 17105-3151
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