Section/division: Telephone number:
Form AIRWORTHINESS: AIRCRAFT INSPECTION & REGISTRATION Fax Number: 011-545-1000
Physical address:
Ikhaya Lokundiza, 16 Treur Close, Waterfall Park, Bekker Street, Midrand, Gauteng
Postal address:
Private Bag X73, Halfway House 1685
Bank: Standard Bank of SA Ltd Service/transaction Fees: See CAR Part 187.01.2
Number: CA 21-03 086 643 3511 Website: www.caa.co.za
DETAILS OF BANK ACCOUNT FOR PAYMENT OF PRESCRIBED FEE Branch Code: Branch: Brooklyn, Pretoria Account Number: 013007971 011245 COMPULSORY CLIENT PAYMENT CODE (to be completed on deposit slip) Over the counter payments EFT, Internet, Wire, Electronic payments
APPLICATION FOR RENEWAL OF A CERTIFICATE OF AIRWORTHINESS Please note the following conditions: 1. Application shall be submitted 60 days prior to C of A expiry date –refer to CAR 21.08.12(a) (1). 2. In terms of CAR SA-CATS 21.08.12A -The record of work accomplished may be submitted by: (a) recording relevant data on the applicable annual maintenance review report form; OR (b) attaching relevant data certified by the appropriately rated AMO, to the applicable annual maintenance review report form; OR (c) attaching copies of the appropriate logbook pages to the applicable annual maintenance review report form.”. 3. 90 days grace period is now covered in the regulations –Refer to CAR 21.08 12(a) (4) failure to comply will warrant action in terms of CAR 21.08.3. 4. In terms of CAR SA-CATS 21.08.12A - If an aircraft is unserviceable at the time of the application for the renewal of the Certificate of Airworthiness, the owner/operator may lodge an application for such renewal together with appropriate fee as prescribed by Part 187. Once the outstanding documentation has been submitted to the Director, within a period of 365 days since the expiry date of the Certificate of Airworthiness, the Certificate of Airworthiness shall be processed. Furthermore, if the information provided demonstrates that the aircraft is serviceable, the Director shall process the application for the renewal.
AIRCRAFT REGISTRATION MARKS 1.
Z
-
CURRENCY FEE PAYMENT
DESCRIPTION
R
c
Currency year 2016 - 2017 Currency year 2017 - 2018 TOTAL PAYABLE
2.
CONTACT DETAILS OF AIRCRAFT MAINTENANCE ORGANIZATION (AMO)
Name of Organization
AMO number
Name of Accountable person Telephone number
Cell phone number
Fax number
e-mail address
3.
DETAILS OF THE AIRCRAFT OWNER
Name of aircraft Owner Postal address Postal code Telephone number
Fax number
E-mail address
4.
DESCRIPTION OF AIRCRAFT
Manufacturer Airframe serial number
Model designation Type certificate number
Date of manufacture
5.
State of manufacture
DESCRIPTION OF ENGINE(S)
Manufacturer CA 21-03
Model designation(s) 21 JULY 2017
Page 1 of 2
Serial number(s) 1.
6.
2.
3.
4.
DESCRIPTION OF PROPELLER(S)
Manufacturer Serial number(s)
7.
Model designation(s) 1.
2.
3.
4.
SUPPORTING DOCUMENTATION 1) 2) 3) 4) 5)
Application form completed in full accompanied by proof of payment Mass and balance Latest report Valid Radio station License Flight Folio (Last record indicating total airframe hours/cycles); Certificate of Release to Service (CRS) (Current Valid Release to Service)
8. CA 43-02/03/05 Form Or Certified Data Or Logbook ( previous 12 months record) (Less than 10 pages only)
CA 43-02/03/05 form correctly completed and up to date by listing appropriate data on the form OR Attaching CA 43-02/03/05 and relevant data 8 A certified by an appropriately rated AMO 8B OR Attaching CA 43-02/03/05 and copies of the appropriate logbook pages
Submission covered in 8 A shall include the following list: (1) Scheduled maintenance checks carried out (Since last C of A renewal) (2) Serialised list of components replaced and/or fitted (Since last C of A renewal); (3) Ads, SBs and all relevant Continuing Airworthiness maintenance performed (Since last C of A renewal); (4) List of Modifications and major repairs embodied (Since last C of A renewal).
Airworthiness Certificate category Standard Restricted required (Please tick applicable box) Airworthiness Design Standard Categories (Please tick applicable box) 8.2 Note : Info below can be obtained from the TCDS Normal Normal category (Rotorcraft) 8.1
Utility
Transport category (Rotorcraft)
Acrobatic
Non-rigid airship
Commuter (Aeroplanes)
Manned free balloon
Transport Category (Aeroplanes)
Other categories(specify)
Experimental
9. DECLARATION I hereby declare that I am, or have applied to be, the registered owner/operator (or the agent acting on behalf of the registered owner/operator) of the aircraft described in paragraph 3 and to the best of my knowledge and belief, the particulars contained in this application are accurate in every respect and show compliance with Part 21 of the Civil Aviation Regulations, 2011, as amended.
SIGNATURE OF APPLICANT / OWNER / AGENT
NAME IN BLOCK LETTERS
DATE
FOR OFFICIAL USE ONLY APPLICATION ACCEPTED
SIGNATURE OF INSPECTOR
CA 21-03
APPLICATION NOT ACCEPTED
NAME IN BLOCK LETTERS
21 JULY 2017
DATE
Page 2 of 2
