Instructions and advice for completing this Application Form
Note: The CAA Standard Rate hourly charge applies.
(Refer to Advisory Circular AC91-Ops1 for 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 aircraft FORMCHECKBOX
Multiple aircraft FORMCHECKBOX (Complete Appendix A)
Application Type: FORMDROPDOWN
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)
RVSM FORMCHECKBOX
ILS Cat II FORMCHECKBOX
ILS Cat III FORMCHECKBOX
EDTO:
120 min FORMCHECKBOX
180 min FORMCHECKBOX
210 min FORMCHECKBOX
240 min FORMCHECKBOX
Navigation
RNP 10 FORMCHECKBOX
RNAV 5 FORMCHECKBOX
RNAV 2 FORMCHECKBOX
RNAV 1
FORMCHECKBOX
RNP 4 FORMCHECKBOX
RNP 2 FORMCHECKBOX
Basic RNP 1 FORMCHECKBOX
Advanced RNP FORMCHECKBOX
RNP APCH FORMCHECKBOX
RNP AR Ops FORMCHECKBOX
RF Legs FORMCHECKBOX
Baro VNAV FORMCHECKBOX
LPV FORMCHECKBOX
FANS 1/A FORMCHECKBOX
ADS-B Out
CASA CAO 82.5 FORMCHECKBOX
EASA AMC 20-24 FORMCHECKBOX
RTCA DO-260A FORMCHECKBOX
RTCA DO-260B FORMCHECKBOX
ADS-C
TBD FORMCHECKBOX
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:
New FORMCHECKBOX
Used FORMCHECKBOX
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 FORMDROPDOWN
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 FORMDROPDOWN
HF Model FORMDROPDOWN
SATCOM Model
SATCOM Data FORMDROPDOWN
SATCOM Voice FORMDROPDOWN
Is SCV integrated to audio, CVR and FDR systems?
FORMDROPDOWN
Is an Exemption against §91.519 held for this aircraft?
FORMDROPDOWN
Exemption No:
Navigation Systems
Qty installed
Inertial Reference System
Model FORMDROPDOWN
Part No
Air Data Computers Model
Model FORMDROPDOWN
Part No
GNSS
Model FORMDROPDOWN
Part No
DME
Model FORMDROPDOWN
Part No
Flight Management Computer
Model FORMDROPDOWN
Part No
Software Version
Flight Control Computer
Model FORMDROPDOWN
Part No
Software Version
Mode Control Panel
Model
Part No
Pitot Static Probes
Model / Part No FORMDROPDOWN
Angle of Attack Vanes
Model / Part No FORMDROPDOWN
Surveillance Systems
Transponder 1
Model Mode S FORMCHECKBOX
FORMDROPDOWN
Part No
Software Version
ELS FORMCHECKBOX
EHS FORMCHECKBOX
Extended Squitter FORMCHECKBOX
Transponder 2
Model Mode S FORMCHECKBOX
FORMDROPDOWN
Part No
Software Version
ELS FORMCHECKBOX
EHS FORMCHECKBOX
Extended Squitter FORMCHECKBOX
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 FORMCHECKBOX
Part 43 App D Altimeter Systems Tests & Inspections
FORMCHECKBOX
Part 43 App E ATC Transponder Tests & Inspections
FORMCHECKBOX
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 FORMCHECKBOX
PBN: RNAV & RNP FORMCHECKBOX
FANS 1/A FORMCHECKBOX
ADS-B FORMCHECKBOX
ADS-C FORMCHECKBOX
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: FORMCHECKBOX
Comments:
Part E – Applicants Declaration
I am signing this form as:
A Senior Person in a Part 119 Certificated operator.
FORMCHECKBOX
Owner / operator of an aircraft engaged in Part 91 operations
only. FORMCHECKBOX
Agent or representative of an OWNER / OPERATOR of an aircraft
engaged in Part 91 operations only. FORMCHECKBOX
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.
4. 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.
5. 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.
Part G – CAA Assessment
1. Airworthiness:
a. RVSM:
i. The aircraft meets the airworthiness requirements specified
in AC 91-4 approval for RVSM operations. FORMCHECKBOX
ii. Aircraft has dual independent communications:
VHF FORMCHECKBOX
HF FORMCHECKBOX
HF + SCV FORMCHECKBOX
iii. Aircraft meets the requirements for: FORMDROPDOWN
iv. Aircraft inspection required: FORMDROPDOWN
v. Inspection sheet raised: FORMCHECKBOX
b. The aircraft meets the airworthiness requirements specified
in AC 91-XX for the following navigation operations:
i. RNP 10 (RNAV 10) FORMCHECKBOX
ii. RNAV 5 (BRNAV) FORMCHECKBOX
iii. RNAV 2 FORMCHECKBOX
iv. RNAV 1 (PRNAV) FORMCHECKBOX
v. RNP 4 FORMCHECKBOX
vi. RNP 2 FORMCHECKBOX
vii. Basic RNP 1 FORMCHECKBOX
viii. RNP 0.3 FORMCHECKBOX
ix. RNP APCH FORMCHECKBOX
x. RNP AR Operations FORMCHECKBOX
xi. Baro VNAV FORMCHECKBOX
xii. LPV FORMCHECKBOX
xiii. RF legs FORMCHECKBOX
xiv. FANS 1/A FORMCHECKBOX
xv. Inertial only navigation time for RNP 10:
x.x hours
xvi. Inertial only navigation time for RNAV 5:
x.x hours
Conditions / limitations / comments:
c. The aircraft meets the airworthiness requirements specified
in AC 91-XX for ADS-B operations in airspace with the following
requirements:
i. CASA CAO 82.5 FORMCHECKBOX
ii. EASA AMC 20-24 FORMCHECKBOX
iii. RTCA DO-260A FORMCHECKBOX
iv. RTCA DO-260B FORMCHECKBOX
Conditions / limitations / comments:
d. The aircraft meets the airworthiness requirements specified
in AC 91-XX for ADS-C operations in airspace with the following
requirements:
i. TBD FORMCHECKBOX
Conditions / limitations / comments:
2. Continued Airworthiness:
a. The aircraft operator is already approved for the conduct of
the operations requested for the same aircraft make and model;
and
b. There are no significant differences from previously approved
aircraft; FORMCHECKBOX
or
c. The aircraft operator has the capability of maintaining the
aircraft in compliance with its type design and AC 91-4 for the
conduct of RVSM operations; FORMCHECKBOX
d. 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.
FORMCHECKBOX
e. 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.
FORMCHECKBOX
f. 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.
FORMCHECKBOX
3. Flight Operations:
a. The aircraft operator is already approved for the conduct of
the operations requested for the same aircraft make and model;
and
b. There are no significant differences from previously approved
aircraft; FORMCHECKBOX
or
c. 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 91-4 in domestic
and oceanic airspace. FORMCHECKBOX
d. 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. FORMCHECKBOX
e. 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. FORMCHECKBOX
f. 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. FORMCHECKBOX
Part G – CAA Approval
Approval Recommendation
Airworthiness FORMDROPDOWN
Name: Date:
Continued Airworthiness FORMDROPDOWN
Name: Date:
Flight Operations FORMDROPDOWN
Name: Date:
Manager Flight Operations Approval
The operations identified in Part G Section 1 are FORMDROPDOWN
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). FORMDROPDOWN
2. Letter(s) of Authorisation issued. FORMCHECKBOX
3. Ops Specs revised and approved. FORMCHECKBOX
4. For RVSM, PARMO Form F2 submitted. FORMCHECKBOX
5. For RVSM, CAA Registration database updated. FORMCHECKBOX
6. ACU Operational Approvals database updated. FORMCHECKBOX
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:
New FORMCHECKBOX
Used FORMCHECKBOX
Previous Registration:
Previous Operator:
State / Country:
Approval Completion
1. RVSM inspection report received and satisfactory (if
required). FORMDROPDOWN
2. Letter(s) of Authorisation issued. FORMCHECKBOX
3. Ops Specs revised and approved. FORMCHECKBOX
4. For RVSM, PARMO Form F2 submitted. FORMCHECKBOX
5. For RVSM, CAA Registration database updated. FORMCHECKBOX
6. ACU Operational Approvals database updated. FORMCHECKBOX
Aircraft 3
Make: Model:
Serial No: Line No: Variable No:
Registration Mark: CAA Aircraft ID: Mode S Code
(hex):C8XXXX
Aircraft History:
New FORMCHECKBOX
Used FORMCHECKBOX
Previous Registration:
Previous Operator:
State / Country:
Approval Completion
1. RVSM inspection report received and satisfactory (if
required). FORMDROPDOWN
2. Letter(s) of Authorisation issued. FORMCHECKBOX
3. Ops Specs revised and approved. FORMCHECKBOX
4. For RVSM, PARMO Form F2 submitted. FORMCHECKBOX
5. For RVSM, CAA Registration database updated. FORMCHECKBOX
6. ACU Operational Approvals database updated. FORMCHECKBOX
Aircraft 4
Make: Model:
Serial No: Line No: Variable No:
Registration Mark: CAA Aircraft ID: Mode S Code
(hex):C8XXXX
Aircraft History:
New FORMCHECKBOX
Used FORMCHECKBOX
Previous Registration:
Previous Operator:
State / Country:
Approval Completion
1. RVSM inspection report received and satisfactory (if
required). FORMDROPDOWN
2. Letter(s) of Authorisation issued. FORMCHECKBOX
3. Ops Specs revised and approved. FORMCHECKBOX
4. For RVSM, PARMO Form F2 submitted. FORMCHECKBOX
5. For RVSM, CAA Registration database updated. FORMCHECKBOX
6. ACU Operational Approvals database updated. FORMCHECKBOX
Aircraft 5
Make: Model:
Serial No: Line No: Variable No:
Registration Mark: CAA Aircraft ID: Mode S Code
(hex):C8XXXX
Aircraft History:
New FORMCHECKBOX
Used FORMCHECKBOX
Previous Registration:
Previous Operator:
State / Country:
Approval Completion
1. RVSM inspection report received and satisfactory (if
required). FORMDROPDOWN
2. Letter(s) of Authorisation issued. FORMCHECKBOX
3. Ops Specs revised and approved. FORMCHECKBOX
4. For RVSM, PARMO Form F2 submitted. FORMCHECKBOX
5. For RVSM, CAA Registration database updated. FORMCHECKBOX
6. ACU Operational Approvals database updated. FORMCHECKBOX
Page 15 of 15CAA 24091/07
Rev 3 : May 2013
