Pt. 60, App. C

14 CFR Ch. I (1-1-19 Edition)

Attachment 4 to Appendix C to Part 60Figure C4F- Sample Statement of Qualification; Configuration List
INFORMATION

STATEMENT of QUALIFICATION
CON!ilGURATION LIST
Date:

Section l. FSTD Information and Characteristics

'

Sponsor Name:
Address:

-

FSTD Location:
Physical Address:

City:
State:
Country:

 - -

City:
State:
Country:
ZIP:

 - 

 - 

Nearest Airport:

 - 

 -  - 

ZIP:
Manager
~onsr

ID No:

(Four Letter FAA Designator)

-

 - -

(Airport Designator)

IQ

Type of Evaluation Requested:

Initial D Upgrade D Continuing Qualification D Special
D Reinstatement

Aircraft Make/model/series:
Initial Qualification:

-

(If Applicable)

lVIIVI/lJlJ/

Upgrade Qualification:

Date:'~

(If Applicable)

 - 

Date:Section=Section Level

-

Manufacturer's
Identification or Serial
Number
DeMQTG

Level
!VllVI UU/

Qualification Basis:

IDA
ID6

Other Technical Information:
FAA FSTD ID No:
(If Applicable)

Convertible FSTD:

!DB

ID

107

c
Provisional Status

 - 

FSTD Manufacturer:

.DYes:

Date of Manufacture:

D

I

MWDD/YYYY

Related FAA ID No.

Sponsor }'STD ID No:

(If Applicable)

Engine model(s) and data revision:

Source of aerodynamic model:

FMS identification and revision level:

Source of aerodynamic coefficient data:

Visual system manufacturer/model:

Aerodynamic data revision number:

I Flight control data revision:

Visual system display:

Mot ion system manufacturer/type:

FSTD computer(s) identification:

.

National Aviation Authority
(If \nnli<'HhiP)

NAA FSTD ID No:

Last NAA Evaluation
Date:

 -  - 

NAA Qualification Level:
NAA Qualification Basis:

-..

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.Section