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Who would actually perform the authorized functions. Form Approved OMB-2120-0033 Expiration Date 08-31-2013 3. U.S. CITIZEN STATEMENT OF QUALIFICATIONS (DAR-DMIR-DER) US Department of Transportation Federal Aviation Administration INSTRUCTIONS: Print or type all entries except signatures Yes No 1. NAME (Last, first, middle) OR ORGANIZATION 4. DATE OF BIRTH 2. BUSINESS OR COMPANY ADDRESS (Number, street, city, state, and ZIP code) 5. BUSINESS PHONE NUMBER 6. BUSINESS FAX NUMBER 7. EMAIL.

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