gaca_gov_sa · form · processed · 1 chunks
GACA الهييه العامه للطيران المدني General Authority of Civil Aviation [Non-Text] APPLICATION FOR 406 MHz ELT/ELT-DT/PLB REGISTRATION INFORMATION <table><tr><td>Type</td><td colspan="3">☐ ELT</td><td colspan="3">☐ ELT-DT</td><td colspan="3">☐ PLB</td></tr><tr><td rowspan="2">23-Digit</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td colspan="9">(23-digit Beacon ID)</td></tr><tr><td rowspan="2">15-Digit</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td colspan="9">(15-digit Beacon ID)</td></tr><tr><td>Manufacturer</td><td colspan="2"></td><td colspan="2">Model No.</td><td colspan="2"></td><td colspan="2">Serial No.</td><td></td></tr></table> REGISTRATION <table><tr><td>□ New Registration Information</td><td>□ De-Registration</td><td>□ Change of Information or Ownership</td></tr><tr><td>□ Replacement of decal (enter the old unique ID number)</td><td></td><td></td></tr></table> OWNER/OPERATOR INFORMATION <table><tr><td>Name</td><td>Email</td><td>Contact Number</td></tr><tr><td></td><td></td><td></td></tr><tr><td>Mailing Address</td><td>City</td><td>State/Province Postal Code Contrary</td></tr></table> AIRCRAFT INFORMATION <table><tr><td>Registration</td><td colspan="5">Manufacturer</td><td>Model</td><td>Serial No.</td><td>Seating Capacity</td></tr><tr><td rowspan="2">Type</td><td colspan="2">□ Single-engine Propeller</td><td colspan="2">□ Single-engine Jet</td><td colspan="4">□ Multi-engine Propeller</td></tr><tr><td colspan="2">□ Multi-engine Jet</td><td colspan="2">□ Helicopter</td><td colspan="4">□ Other</td></tr><tr><td>Usage</td><td colspan="8">□ Commercial □ Non-commercial □ Government Military □ Government non-military</td></tr><tr><td>Radio Equipment (Check all that apply)</td><td colspan="6">□ VHF □ MF □ HF □ SSB □ Other</td><td>Principal Aerodrome</td><td colspan="2"></td></tr><tr><td>Survival Equipment (Describe and List Quantity)</td><td colspan="9">□ Deployable □ Fixed</td></tr></table> EMERGENCY CONTACT INFORMATION (Please Indicate Someone Other Than the Owner) <table><tr><td colspan="4">Name of Primary 24-Hour Emergency Contact</td><td colspan="2">Name of Primary 24-Hour Emergency Contact</td></tr><tr><td>Name</td><td>Home</td><td>Work</td><td>Cellular</td><td>Name</td><td>Home Work Cellular</td></tr><tr><td>Contact No.</td><td>□</td><td>□</td><td>□</td><td>Contact No.</td><td>□ □ □</td></tr><tr><td>Name</td><td>Home</td><td>Work</td><td>Cellular</td><td>Name</td><td>Home Work Cellular</td></tr><tr><td>Contact No.</td><td>□</td><td colspan="2">□</td><td>Contact No.</td><td>□ □ □</td></tr><tr><td>Name</td><td>Home</td><td>Work</td><td>Cellular</td><td>Name</td><td>Home Work Cellular (</td></tr><tr><td>Contact No.</td><td>□</td><td colspan="2">□</td><td>Contact No.</td><td>□ □ □</td></tr></table> APPLICANT <table><tr><td>Name</td><td>Signature</td><td>Date</td></tr><tr><td></td><td></td><td></td></tr></table> NOTE Any live beacon test must be coordinated with the Saudi Arabia Mission Control Center Email: SAMCC.SAR@sans.com.sa, Tel: 0126150170, Fax: 0126150171 GACA-AVSES-AIR-F004 Rev: 6, Date: 13 Apr 25 Page 1 of 1