WAA WEIGHT CERTIFICATION

(please type or print)

WAA File Number (issued after sanction):

Pilot Name:

Aircraft Make:

Model:

Aircraft Number:

WAA weight category:

Empty wt. (excludes pilot, crew,

fuel,payload/baggage).......................:________

Pilot and Crew Wt...........................:________

Fuel.................................................:________

Payload/Baggage.............................:________

Total weight at take-off....................:________

Total Number of Persons (Pilot and Crew)....:________

Percent Pilot and Crew Wt of Total weight...:________

Maximum gross take-off weight of aircraft as allowed by

manufacturer................................:________

A description of how all of the above weights were determined is required.

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

signature:

print name:

title:

organization:

address:

telephone:

date:

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