TAKE-OFF CERTIFICATION

WAA File Number(issued after sanction):

Name of pilot:

Aircraft make:

Model:

Aircraft Number:

Airport Name/City/Other

Latitude:

Longitude:

Take-off Date:

Take-off time (last contact with water/ground/ship)

(hh:mm:ss)_____________UTC

Time source:

Take-off observed from:

This is to certify that I observed the above aircraft and pilot take-off at the place and time recorded above and that I have been designated or accepted by the WAA to make this official observation. I further certify that I understand that this information will used for evaluation to determine the success of an attempt to set an international aircraft record.

signature:

print name:

title:

organization:

address:

telephone:

date:

This form should be returned directly to the WAA:

World Aeronautics Association

Records Board

P.O. Box 390534

Mt. View, CA 94039-0534

USA

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