January 23, 2004

Aircraft Registration Branch, AFS-750
P.O. Box 25504
Oklahoma City, OK  73125-0504

Dear Sir or Madam:

This is a request for a United States identification number assignment for my amateur-built aircraft.

Aircraft description:

Make/builder    -  Scrivner 

Type                  -  Glider

Model               - Quicksilver MX

Serial Number  - 113

This aircraft has not previously been registered anywhere.   ( reference section 47.15(a) (l) )

A reserve N-number - N 69QT has been requested, paid for, and confirmed.  Please see attached copy of confirmation.

Attached is a Check, # 6662, in the amount of $5.00  as and for the registration fee.



Charles L. Scrivner ________________________________  Owner

4040 Knox Ave.
Rosamond, Ca.  93560