1 THE OPERATOR THE OPERATOR IS A PRIVATE INDIVIDUAL

1. The operator

The operator is a private individual:

Ms Mr

Name:       First name:      

The operator is an organisation:

Name of the organisation:      

Trading name:      

Operator declared since 1 January 2016 - Operator number:      

Undeclared operator with

permission to perform experiments

a specific authorisation (e.g. foreign operators)

Address

Number:       Street:       Place:      

Post code:       Post box:       Cedex:       Town:      

Country:      

Contact:

Ms Mr Name:       First name:       Function:      

Mobile:       e-mail:      @     

2. Flight conditions

Particular activities

Experiments

3. Requested prefectural exemption(s)

Exemption from the ban on night flights:

A

Particular activities in VISULA LINE OF SIGHT at NIGHT under the conditions of S1 or S3

B

Other cases of particular activities at NIGHT (in-sight flights under conditions other than those of scenarios S1 or S3, or out-of-sight flights)

C

Experiments at NIGHT

Exemptions from maximum heights:

D

Particular activities or experiments, BEYOND LINE OF SIGHT, with:

• an aircraft weighing more than 2kg and at a height greater than 50 m above the ground, or

• an aircraft weighing less than 2kg and at a height greater than 150 m above the ground.

E

VISUAL LINE OF SIGHT experiments at heights above 150 m

• Night time:

• at latitudes between 30° and 60°, night time starts 30 minutes after sunset and ends 30 minutes before sunrise;

• at latitudes equal to or lower than 30°, night time starts 15 minutes after sunset and ends 15 minutes before sunrise.

• - See the definition of “VLOS flightt” and “BVLOS flight” in article 2-2 of the “Airspace” Order.

• See the conditions of scenarios S1 and S3 in paragraph 1.3 of appendix III of the “Aircraft” Order.

• If the flights take place in a part of the airspace that allows for the segregation of remotely piloted aircraft and other users (e.g., Temporary Restriction Zones), exemptions A, B and C above are unnecessary and do not have to be requested (see article 3, item 4 of the Space Order).

• If the flights take place in a part of the airspace that allows for the segregation of remotely piloted aircraft and other users (e.g., Temporary Restriction Zones), exemptions D and E above are unnecessary and do not have to be requested (see articles 8-2 and 9-2 of the Space Order).

4. Date(s) of the flights

Start Date:       Time:      h       min

(DD/MM/YYYY) (local time in 24h format)

End Date:       Time:      h       min

(DD/MM/YYYY) (local time in 24h format)

5. The aircraft

1

Constructor:       Model:       Serial N°:      

Class:       Captive aircraft: yes no Maximum planned weight for the flights:       kg

2

Constructor:       Model:       Serial N°:      

Class:       Captive aircraft: yes no Maximum planned weight for the flights:       kg

3

Constructor:       Model:       Serial N°:      

Class:       Captive aircraft: yes no Maximum planned weight for the flights:       kg

4

Constructor:       Model:       Serial N°:      

Class:       Captive aircraft: yes no Maximum planned weight for the flights:       kg

6. Description of the flights

Site n° 1

Outside populated areas In congested areas Close to a gathering of persons (please describe):      

Note: Attach a recent plan or satellite image with a precise plan of operating aera - See §7

Aircraft that may be used: All Otherwise, please specify: 1 2 3 4

Description of the flights: Maximum flying height:       m Maximum distance of the remote pilot:       m

In sight Out of sight Maximum flying speed:       m/s

Controlled/regulated airspace that may be entered:      

Purpose of the flights and substantiation of the need for an exemption:      

Site n° 2

Outside populated areas In congested areas Close to a gathering of persons (please describe):      

(Enclose a map/diagram of the precise zone of use of the drone – See paragraph 7)

Aircraft that may be used: All Otherwise, please specify: 1 2 3 4

Description of the flights: Maximum flying height:       m Maximum distance of the remote pilot:       m

In sight Out of sight Maximum flying speed:       m/s

Controlled/regulated airspace that may be entered:      

Purpose of the flights and substantiation of the need for an exemption:      

7. Documents to be enclosed

The file contains the following documents:

• A copy of the acknowledgement of receipt of the declaration of activity, of the specific authorisation or of the permission (enclose these documents as soon as they are available, if they were unavailable when the initial request was made);

• Place/layout plan (aeronautical chart, photos or others);

• Precise zone where the drone will fly and position of the remote pilot and any third parties (map/diagrams, etc.);

Use recent plans or satellite images

• Night flights:

  • description of the means of lighting the drone and the zone where it flies;

  • where appropriate, a copy of the request for the creation of a Temporary Restriction Zone (ZRT) or a copy of the notification of its creation;

• Exemptions from maximum flying altitudes: a description of the precautions that will be taken to guarantee separation from other aircraft (air traffic control procedures, observers, means of lighting, etc.)

8. Operator commitment

“I, the undersigned, representing the operator identified in paragraph 1 above,

do hereby certify the accuracy of the information in this declaration.

I hereby agree to:

• meet all the regulatory requirements applicable to the planned operations, and in particular for the aircraft used and the remote pilots, in the following paragraphs of appendix III of the above-mentioned order:

2.3 Conditions specific to aerostats

2.4.1 Conditions specific to captive aircraft

2.5.1 a), b), c), d) Conditions specific to non-captive aircraft

2.6 Conditions specific to aircraft used in scenario S2

2.7 Conditions specific to non-captive aerodynes weighing more than 2kg used in scenario S3

2.8 Conditions specific to aircraft used in scenario S4

4.1 Practical training identified by the operator to perform the particular activities in question

• refrain from using the aircraft under conditions where there would be a risk to other aircraft or persons or property on the ground, including in the event of a probable failure.

• carry out a site inspection to ensure that the site is appropriate for the proposed operation

declare that an insurance policy has been taken out covering risks related to the operations. “

In:       On:      

(DD/MM/YYYY)

Name:      

First name:      

Function (organisations):