Instructions and advice for completing this Application Form

Note: The CAA Standard Rate hourly charge applies.
Refer to Advisory Circular AC91-Ops1for the instructions to complete this application.
The charges associated with the operational approvals will be invoiced to the applicant.
Applications must be submitted to CAA not less than 28 days prior to the date required.
To reduce time and costs, this form is intended to be revised for additional applications after the initial approvals for an aircraft type.

Brief Details

Make:Model:

Single aircraftMultiple aircraft(Complete Appendix A)

Application Type:

Change being made:

Revision History

Revision No:Date:

CAA Work Request No: (To be completed by the CAA)

Part A – Details of Applicant

Name of Operator:

Client ID No. (if known)
Address for Service: Civil Aviation Act, s8, requires applicants to provide an address for service (ie, a physical address) and to promptly notify the Director of any changes.
Tel: / Fax: / Email:
Postal Address: (If different from Address for Service.)
Tel: / Fax: / Email:
Person or organisation who can be contacted for further information concerning this application:
Name:
Designation:
Address:
Tel: / Mob: / Email:

Approvals Sought:(Check those required)

RVSMILS Cat IIILS Cat III

EDTO:

120 min180 min210 min240 min

Navigation

RNP 10RNAV 5RNAV 2RNAV 1

RNP 4RNP 2Basic RNP 1Advanced RNP

RNP APCHRNP AR Ops

RF LegsBaro VNAVLPV

FANS 1/A

ADS-B Out

CASA CAO 82.5EASA AMC 20-24

RTCA DO-260ARTCA DO-260B

ADS-C

TBD

Part B – Aircraft and Equipment Details

Make:Model:

Serial No:Line No: Variable No:

Registration Mark:CAA Aircraft ID: Mode S Code (hex):C8XXXX

Aircraft History:

NewUsed

Previous Registration:

Previous Operator:

State / Country:

For multiple aircraft of the same make and model complete the continuation sheet in Appendix A.

Aircraft Documentation

(Insert document number, revision / date and reference information)

Flight Manual:

Air No:Manufacturer No: Rev:

RVSM Approvals

AFM Reference

SIL / SB

Navigation Approvals

AFM / Approval Doc References

AFM / Approval Doc References

AFM / Approval Doc References

ADS-B Approvals

Approvals held

AFM Reference

Relevant Approval Doc

ADS-C Approvals

Aircraft ELA

Aircraft Software Configuration List

Maintenance Planning Document

Aircraft Maintenance Manual

IPC

Wiring Diagram Manual

Structural Repair Manual

Configuration Deviation List

MMEL

Operator MEL / DDPG

Aircraft Equipment Details

Communications Systems

(Insert Make, Model & P/N)

Qty installed

VHF Model

HF Model

SATCOM Model

SATCOM Data

SATCOM Voice

Is SCV integrated to audio, CVR and FDR systems?

Is an Exemption against §91.519 held for this aircraft?Exemption No:

Navigation Systems

Qty installed

Inertial Reference System

Model

Part No

Air Data Computers Model

Model

Part No

GNSS

Model

Part No

DME

Model

Part No

Flight Management Computer

Model

Part No

Software Version

Flight Control Computer

Model

Part No

Software Version

Mode Control Panel

Model

Part No

Pitot Static Probes

Model / Part No

Angle of Attack Vanes

Model / Part No

Surveillance Systems

Transponder 1

ModelMode S

Part No

Software Version

ELSEHSExtended Squitter

Transponder 2

ModelMode S

Part No

Software Version

ELSEHSExtended Squitter

Part C – Continued Airworthiness

Maintenance Organisation

Contact Details:

Name:

Phone:Mobile:Email:

Maintenance facilities to be used:

Procedures for managing maintenance providers:

Part 43 specified maintenance completed:

Part 43 App B Radio Station Inspection

Part 43 App D Altimeter Systems Tests & Inspections

Part 43 App E ATC Transponder Tests & Inspections

Comments:

Maintenance Practices

(Insert document number, revision / date and reference information)

Maintenance schedule

Configuration management

Modifications / Repairs

Maintenance Practices

Use of BITE

Static System Maintenance

Skin Waviness Checks

Non-Compliant Aircraft

Notification Procedure (maintenance)

Notification Procedure (operations)

Notification Procedure (CAA)

Corrective Action Procedures

Maintenance Training

Test Equipment

Documentation

RVSM Test Equipment

Accuracy (0.01% or 4:1)

Calibration Schedule

Audit Programme

Maintenance Practices

Comments:

Part D – Operational Training and Competency

Contact Details:

Name:

Phone:Mobile:Email:

Training programme submitted:

RVSM

PBN: RNAV & RNP

FANS 1/A

ADS-B

ADS-C

Operator Practices and Procedures - RVSM

Flight Planning

Pre-Flight

Procedures prior to RVSM airspace entry

In-Flight Procedures

ATC Phraseology

NAT Airspace Procedures

Verification / Monitoring Programme

Operator Practices and Procedures –PBN: RNAV & RNP

Flight Planning

Pre-Flight

Procedures prior to RNP airspace entry

In-Flight Procedures

ATC Phraseology

Special Airspace Procedures

Training

Operator Practices and Procedures – RNP / FANS 1/A

Flight Planning

Pre-Flight

Procedures prior to RNP airspace entry

In-Flight Procedures

ATC Phraseology

Special Airspace Procedures

Training

Operator Practices and Procedures – ADS-B / ADS-C

Flight Planning

Pre-Flight

Procedures prior to ADS-B airspace entry

In-Flight Procedures

ATC Phraseology

Special Airspace Procedures

Training

Crew training completed:

Comments:

Part E – Applicants Declaration

I am signing this form as:

A Senior Person in a Part 119 Certificated operator.

Owner / operator of an aircraft engaged in Part 91 operations only.

Agent or representative of an OWNER / OPERATOR of an aircraft engaged in Part 91 operations only.

Giving false or misleading information is an offence under the regulations.

  1. I declare that the information provided in this application form is true and correct.
  2. I understand that the information provided in this application will allow CAANZ to calculate an estimate for service for processing this application.
  3. I understand and agree that the cost estimate may change, and processing the application may be delayed if:
  • the application does not accurately and completely identify my/our requirements; or
  • the details in this application are subsequently changed; or
  • adequate supporting documentation has not been provided.
  1. I understand and agree that for CAANZ to proceed with this application, I must:
  • accept the cost estimate,
  • forward the prescribed payment; and
  • forward all supporting documentation to CAANZ.
  1. If I am signing this application as an agent, I declare that I have obtained the necessary Power of Attorney authorising me to sign on behalf of the applicants.

Name: Date:

There is no signature required on this form; the presence of the name of the individual in this field is deemed to be a signature.

Part F – Submitting Your Application

Have you attached all required documentation as indicated throughout the application? All supplemental information should be in an electronic format.

After reviewing your application, CAANZ will advise you if any additional information is required.

Page 1of15CAA 24091/07

Rev3: May 2013

Part G – CAA Assessment

  1. Airworthiness:
  2. RVSM:
  3. The aircraft meets the airworthiness requirements specified in AC 91-4 approval for RVSM operations.
  4. Aircraft has dual independent communications:
    VHFHFHF + SCV
  5. Aircraft meets the requirements for:
  6. Aircraft inspection required:
  7. Inspection sheet raised:
  8. The aircraft meets the airworthiness requirements specified in AC 91-XX for the following navigation operations:
  9. RNP 10 (RNAV 10)
  10. RNAV 5 (BRNAV)
  11. RNAV 2
  12. RNAV 1 (PRNAV)
  13. RNP 4
  14. RNP 2
  15. Basic RNP 1
  16. RNP 0.3
  17. RNP APCH
  18. RNP AR Operations
  19. Baro VNAV
  20. LPV
  21. RF legs
  22. FANS 1/A
  23. Inertial only navigation time for RNP 10:x.x hours
  24. Inertial only navigation time for RNAV 5:x.x hours

Conditions / limitations / comments:

  1. The aircraft meets the airworthiness requirements specified in AC 91-XX for ADS-B operations in airspace with the following requirements:
  2. CASA CAO 82.5
  3. EASA AMC 20-24
  4. RTCA DO-260A
  5. RTCA DO-260B

Conditions / limitations / comments:

  1. The aircraft meets the airworthiness requirements specified in AC 91-XX for ADS-C operations in airspace with the following requirements:
  2. TBD

Conditions / limitations / comments:

  1. Continued Airworthiness:
  2. The aircraft operator is already approved for the conduct of the operations requested for the same aircraft make and model; and
  3. There are no significant differences from previously approved aircraft;
    or
  4. The aircraft operator has the capability of maintaining the aircraft in compliance with its type design and AC 91-4for the conduct of RVSM operations;
  5. The aircraft operator has the capability of maintaining the aircraft in compliance with its type design and AC 91-XX for the conduct of the navigation operations listed in 1. b above.
  6. The aircraft operator has the capability of maintaining the aircraft in compliance with its type design and AC 91-XX for the conduct of operations requiring ADS-B listed in 1. c above.
  7. The aircraft operator has the capability of maintaining the aircraft in compliance with its type design and AC 91-XX for the conduct of the ADS-C operations listed in 1. d above.
  8. Flight Operations:
  9. The aircraft operator is already approved for the conduct of the operations requested for the same aircraft make and model; and
  10. There are no significant differences from previously approved aircraft;
    or
  11. The aircraft operator has been assessed as having the required training and operational competency for the conduct of RVSM operations in accordance with CAR §91 and AC 91-4in domestic and oceanic airspace.
  12. The aircraft operator has been assessed as having the required training and operational competency for the conduct of the navigation operations listed in 1. b above in accordance with CAR §91 and AC 91-XX.
  13. The aircraft operator has been assessed as having the required training and operational competency for the conduct of operations in airspace requiring ADS-B as listed in 1. c above in accordance with CAR §91 and AC 91-XX.
  14. The aircraft operator has been assessed as having the required training and operational competency for the conduct of operations in airspace requiring ADS-C as listed in 1. D above in accordance with CAR §91 and AC 91-XX.

Part G – CAA Approval

Approval Recommendation

Airworthiness

Name:Date:

Continued Airworthiness

Name:Date:

Flight Operations

Name:Date:

Manager Flight Operations Approval

The operations identified in Part G Section 1 are subject to the conditions and limitations specified below:

Conditions and Limitations

Manager Flight Operations Approval

Name:Date:

Approval Completion

  1. RVSM inspection report received and satisfactory
    (if required).
  2. Letter(s) of Authorisation issued.
  3. Ops Specs revised and approved.
  4. For RVSM, PARMO Form F2 submitted.
  5. For RVSM, CAA Registration database updated.
  6. ACU Operational Approvals database updated.

Page 1of15CAA 24091/07

Rev3: May 2013

Appendix A: Additional Aircraft

Aircraft 2

Make:Model:

Serial No:Line No: Variable No:

Registration Mark:CAA Aircraft ID: Mode S Code (hex): C8XXXX

Aircraft History:

NewUsed

Previous Registration:

Previous Operator:

State / Country:

Approval Completion

  1. RVSM inspection report received and satisfactory
    (if required).
  2. Letter(s) of Authorisation issued.
  3. Ops Specs revised and approved.
  4. For RVSM, PARMO Form F2 submitted.
  5. For RVSM, CAA Registration database updated.
  6. ACU Operational Approvals database updated.

Aircraft 3

Make:Model:

Serial No:Line No: Variable No:

Registration Mark:CAA Aircraft ID: Mode S Code (hex): C8XXXX

Aircraft History:

NewUsed

Previous Registration:

Previous Operator:

State / Country:

Approval Completion

  1. RVSM inspection report received and satisfactory
    (if required).
  2. Letter(s) of Authorisation issued.
  3. Ops Specs revised and approved.
  4. For RVSM, PARMO Form F2 submitted.
  5. For RVSM, CAA Registration database updated.
  6. ACU Operational Approvals database updated.

Aircraft 4

Make:Model:

Serial No:Line No: Variable No:

Registration Mark:CAA Aircraft ID: Mode S Code (hex): C8XXXX

Aircraft History:

NewUsed

Previous Registration:

Previous Operator:

State / Country:

Approval Completion

  1. RVSM inspection report received and satisfactory
    (if required).
  2. Letter(s) of Authorisation issued.
  3. Ops Specs revised and approved.
  4. For RVSM, PARMO Form F2 submitted.
  5. For RVSM, CAA Registration database updated.
  6. ACU Operational Approvals database updated.

Aircraft 5

Make:Model:

Serial No:Line No: Variable No:

Registration Mark:CAA Aircraft ID: Mode S Code (hex): C8XXXX

Aircraft History:

NewUsed

Previous Registration:

Previous Operator:

State / Country:

Approval Completion

  1. RVSM inspection report received and satisfactory
    (if required).
  2. Letter(s) of Authorisation issued.
  3. Ops Specs revised and approved.
  4. For RVSM, PARMO Form F2 submitted.
  5. For RVSM, CAA Registration database updated.
  6. ACU Operational Approvals database updated.

Page 1of15CAA 24091/07

Rev3: May 2013