Date Waiver Needed__26-Jul-2004___.  Previous Waiver No.  (If applicable) ____________

(Processing takes approximately 7 days)

Fax completed forms to (571) 227-1945

I.                     COMPANY/AIRCRAFT INFORMATION:

Name of Company: _Alaska Airmen’s Association, Inc.__________________________

Mailing Address:  _4451 Aircraft Dr. #G________________Anchorage, AK_______________99502__

                                                             Street Address                                                              City/State                                             Zip Code

Company Telephone No.: __907-245-1251________ Company Fax No.: __907-245-1259_______________

Purpose of Flight: ____Demonstration Flight extending Int’l VFR Route B-369 ________________

Please specify whether flight is Cargo, Passenger or Both _Not Applicable/General Aviation/Pleasure Flight

Name and Telephone Number of Requestor: __Mona Holmes, Alaska Airmen’s Assoc., 907-245-1251___

Flight Itinerary: REQUEST WAIVER TO OPERATE TO/FROM AND WITHIN THE UNITED STATES

Type of Aircraft __Cessna T210M______________ Aircraft Call Sign _______N498TB_______________

State of Aircraft Registry & Tail No. ___Alaska, N498TB___________________________________________

Aircraft Maximum Certified Takeoff Gross Weight: ______4000 lbs________________________________

II.                   CREW AND PASSENGER INFORMATION:

(Note: Place of Birth, if US City and State, if Foreign City and Country)

Last Name

First Name

Middle Name

Date of Birth (yyyymmdd)

City/Country of Birth

Passport Number (Use Text Format)

Passport Country of Issuance

If US provide Green Card # and/or SSN

Bureau

Todd

Marvin

 

Wooster, OH / USA

 

 

 

Skogstad

James

 

 

Helena, MT / USA

 

 

 

Maguire

Felix

Michael

 

Dragheda, Ireland

 

 

 

 Holmes

Ramona

Teresa

 

SF, CA /USA

 

 

 

III.                 FLIGHT ITINERARY:

List all legs of flight (4 letter identifiers only) with dates of travel:  (Ex: Feb 14 – 23. KMIA-LFPB-KMIA)

__     Aug 01-04, 2004  PAOM-UHMD-UHMA-UHMD-PAOM (Request alternate dates in event of weather/mechanical issues: Aug 04-06, 2004) ___________________________________________________________________________________________________________________________________________________________

 

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SECURITY STATEMENT

 

Aircraft Registration Number:  ____N489TB_________

Type of Aircraft:  ____Cessna T210M___ 

I.              AFFIRMATION:  Requestor/Signature must affirm to each of the following:

                (Please check (X) each criteria)

                _X____ Access to aircraft has been properly controlled by company representatives.

                _X___ A senior company representative has verified the identity and authorization of each crewmember        and passenger.

                _X___ Only authorized passengers are on board the aircraft.

                _X___ The aircraft will not deviate from the approved air traffic flight plan.

                _X___ The pre-flight inspections include a search of the cargo and cabin areas to ensure no foreign objects,                explosives, etc. have been placed on board.

II.            How is the aircraft secured when not operational?  (locked hangar, fenced area with gate access,   security guards, etc…)

Fenced area with gate access, airport security

III.           How are the personnel on board vetted/positively identified/security reviewed before boarding the   aircraft?

All are personally known to pilot/owner and all are members of Alaska Airmen’s Association, Inc.

IV.           Additional security measures taken (if any) are:

Pre-flight briefing and knowledge of international regulations.

V.            SIGNATURE OF CORPORATE SECURITY DIRECTOR, COMPANY PRESIDENT,          EQUIVALENT OR DESIGNEE.

 

___________________________________________Administrative Manager/Alaska Airmen’s Association

                Signature                                                              Title

 

______7-12-04_______________________________907-245-1251____________________________________

                Date                                                                        Contact Number

Fax completed forms to (571) 227-1945

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