MINNESOTA DEPARTMENT OF TRANSPORTATION OFFICE OF AERONAUTICS 222 East Plato Blvd. St. Paul, MN

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1 MINNESOTA DEPARTMENT OF TRANSPORTATION OFFICE OF AERONAUTICS 222 East Plato Blvd. St. Paul, MN APPLICATION FOR COMMERCIAL OPERATIONS LICENSE Please fill in all applicable spaces and return to the address listed above. For help call , or in greater Minnesota. Original Application Renewal Application Additional Endorsements COMPANY NAME ADDRESS FOR OFFICE USE ONLY Present License Number Expiration Date Check Number Amount Received WEB SITE COMPANY OWNER (If partnership or corporation, attach data on all officers) ADDRESS CITY STATE ZIP COMPANY MANAGER ADDRESS CITY STATE ZIP OPERATING FROM THE FOLLOWING MINNESOTA AIRPORT(S) UNICOM FREQUENCY (if different from CTAF) General Commercial Operations Endorsements (Indicates applicable sections of Mn/DOT Aeronautics Rules Chapter 8800) Aerial Photography ( ) Aerial Spraying or Dusting ( ) The applicant hereby certifies that all applicable requirements of the Minnesota Department of Agriculture ( ) have been met and that the license number issued by the Minnesota Department of Agriculture is: Aerial Survey ( ) Air Rides ( ) Aircraft Dealer ( ) Aircraft Rental/Leasing ( ) Aircraft Servicing, Maintaining and Repairing ( ) Banner Towing ( ) Fire Detection/Suppression ( ) Flight School ( ) (List courses below) Pipeline Patrol ( ) Powerline Patrol ( ) Skydiving ( ) Skywriting ( ) Thermal Imaging (UAV) ( ) Unmanned Aerial Vehicle (UAV) ( )

2 We do not license the following activities, but we do maintain a database of operators that supply these services and we make this information available online and upon request. Please check those that apply to your operation and cross out any that no longer apply. Air Ambulance Aircraft Charter Aircraft Fueling Aircraft Interiors Aircraft Painting Aircraft Restoration Avionics Shop Chart Sales Engine Overhaul Fixed Base Operator Floats Glider Towing Training (not leading to a certificate or rating) Propeller Shop Salvage Skis Transient Hangar Miscellaneous (services not listed above) IF BOX IS CHECKED, PLEASE INCLUDE DOCUMENTATION WITH THIS APPLICATION Authorization for use of airport from local authorities, if applicable ( Subp 8) Certificate of Insurance with endorsement giving 5-day Notice of Cancellation to Commissioner of Transportation ( Subp 15, Subp 7, Subp 4, Subp 8, Subp 3) Maintenance Agreement ( Subp 12) School Bond ( Subp 8) Appropriate Curriculums ( Subp 5) Flight School Rules ( Subp 6) Insurance Advisory Form ( Subp 7, Subp 4) FAA Commercial Agricultural Aircraft Operator Certificate ( Subp 7) LIABILITY INSURANCE The applicant hereby certifies that all applicable insurance requirements contained in Chapter have been met. NAME OF INSURANCE COMPANY LOCAL AGENCY AREA CODE-TELEPHONE NO. POLICY NUMBER EXPIRATION DATE AIRCRAFT OR DRONES USED The applicant hereby certifies that all aircraft/drones used for commercial purposes are now registered with the Commissioner of Transportation. To register aircraft/drones call or MAKE, MODEL & YEAR FAA REGISTRATION NUMBER MAKE, MODEL & YEAR FAA REGISTRATION NUMBER

3 PERSONNEL A. PILOTS/FLIGHT INSTRUCTORS NAME FAA CERTIFICATE NUMBER B. MECHANICS NAME FAA CERTIFICATE NUMBER DEALERS: All aircraft held for sale and used for demonstration purposes must be listed with the Commissioner on an Aircraft Withholding Form which must be submitted within seven days of any transaction involving the buying, selling or brokering of any aircraft. FEES AND SIGNATURE The following fee shall accompany this application: (Make checks payable to "Treasurer, State of Minnesota") Commercial Operations License (various endorsements, including aircraft dealer)... $30.00 Commercial Operations License (aircraft dealer endorsement only)... $10.00 Additional endorsements on current commercial operations license... no fee The applicant hereby certifies that all of the above statements are true and correct. SIGNATURE DATE ADDRESS CITY, STATE, ZIP Forms are available online at: Inspected and Recommended for Approval: FOR DEPARTMENT USE ONLY Commissioner or Authorized Representative Date Approved

4 Collection of Social Security Numbers and Minnesota Business Identification Numbers In accordance with applicable Minnesota laws, if you do not provide the following information along with your license application/renewal application we cannot issue you a license and will be forced to take action to ensure that you are not providing the services for which you were requesting the license. No one will be given access to your private data except those permitted by law. A more detailed explanation is provided on the reverse side of this document. Business Name, all DBAs and Address: Federal EIN (FEIN) or MN Tax ID or Social Security Number (SSN): Applicant(s) Name and Address:

5 Minnesota Statute 270C.72 requires all licensing authorities to require applicants to provide the applicant s Social Security number and Minnesota business identification number on all license applications. These numbers must be provided to the Commissioner of Revenue upon request along with the applicant s name and address and the business name and address. We want you to know that Social Security numbers and Minnesota business identification numbers will be treated as private data under the Minnesota Government Data Practices Act. This form was created to gather the information separate from the rest of the license application. While the rest of the license application becomes part of the public file, this data will be kept in a secure file and the actual form will be destroyed. If you would like to know more about the requirement for this data and how the data will be treated we suggest that you use these links: 270C.72 TAX CLEARANCE; ISSUANCE OF LICENSES. Minnesota Government Data Practices Act SOCIAL SECURITY NUMBERS E.59 USE OF SOCIAL SECURITY NUMBERS. Information on Business Taxes business/taxes/ If you have additional questions please contact: Rick Braunig or rick.braunig@state.mn.us