Federal Aviation Administration, DOT

Pt. 60, App. D

Attachment 4 to n.~c-P"
.."''"
Figure D4F- Sample Statement Qutalifc~(]n
INFORMATION

Configuration List

STATEMENT of QUALIFICATION
CONlflGURATION LIST
Date:

Section!. FSTDJnformatiQilrtnd Characteristics
Sponsor Name:
Address:

FSTD Location:
Physical Address:

 - 

1-

City:
State:
Country:
ZIP:

City:
State:
Country:
ZIP:
Manager
Sponsor ID No:

Nearest Airport:
I (Airport Desitmator)

 - 

I (Four Letter FAA Designator)

I0

Type of Evaluation Requested:

0

Aircraft Make/model/series:
Initial Qualification:

-

(If Applicable)

MM/JJVI

Initial 0 Upgrade
Reinstatement

Date: _Level

Upgrade Qualification:

Date:_ Level

(If Applicable)

Mi /LJU/

Qualification Basis:

0

 - 

Continuing Qualification 0 Special

Manufacturer's
Identification or Serial
Number
OeMQTG

IDA

lOB

106

107

-:~

I0

Interim C
IDe
I D Provisional Status

T

IDD

',

Other Technical Information:
D IDNo:
FSTD:

I

A IDNo.

I

 - 

FSTD Manufacturer:

DYes:

Date of Manufacture:

-MMIDD/YYYY

Sponsor FSTD lD No: _ _ _ _

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:

Flight control data revision:

Visual system display:

Mot ion system manufacturer/type:

FSTD computer(s) identification:

I ~;1

Aviation Authority

(If Applicable)

NAA FSTD ID No:

Last NAA Evaluation
Date:

 -  - 

NAA Qualification Level:
NAA Qualification Basis:

-,,'

485

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