Application For Type Certificate, Production Certificate, Or Supplemental Type Certificate Page 3
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3U.S. DEPARTMENT OF TRANSPORTATION
FORM APPROVED
FEDERAL AVIATION ADMINISTRATION
OMB No. 2120-0018
EXP DATE: 4/30/2015
APPLICATION FOR TYPE CERTIFICATE, PRODUCTION CERTIFICATE, OR SUPPLEMENTAL TYPE
CERTIFICATE
1. Name Of Applicant
2. Application made for :
3. Product Involved
Aircraft
Type Certificate
Production Certificate
Engine
Supplemental Type Certificate
Amended Type Certificate
Propeller
Amended Supplemental Type Certificate
4. Address
b.
City
State
c. Zip Code
TYPE CERTIFICATE (Complete item 5a below)
5.
a. Model designation(s) (All models listed are to be completely described in the required technical data, including drawings
representing the design, material, specifications, construction, and performance of the aircraft, aircraft engine, propeller
which is the subject of this application.)
6. PRODUCTION CERTIFICATE (Complete items 6a-c below. Submit with this form, in manual form, one copy
of quality control data or changes thereto covering new products, as required by applicable FAR.)
a. Factory address (if different from above)
b. Application is for
P.C. No.
New production certificate
Additions to production
Certificate (Give P.C. No.)
T.C./S.T.C. No.
c. Applicant is holder of or a licensee under a Type Certificate or a Supplemental Type Certificate
(Attach evidence of licensing agreement and give certificate number)
7. SUPPLEMENTAL TYPE CERTIFICATE (Complete items 7a-d below)
a. Make and model designation of product to be modified
b. Description of modification
c. Will data be available for sale or release to other persons?
d. Will parts be manufactured for sale? (Ref. FAR 21.303)
Yes
No
Yes
No
8. CERTIFICATION - I certify that the above statements are true.
Signature of certifying official
Title
Date
FAA Form 8110-12 (
) SUPERSEDES PREVIOUS EDITION
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