004-application-for-air-navigation-service-certificate

gaca_gov_sa · form · processed · 2 chunks
document_type=form entity=format:application/pdf entity=language:ar language=en taxonomy_l1=transport taxonomy_l2=aviation taxonomy_l3=air_traffic_services validity=valid validity_confidence=0.6
GACA
الطبيه العامه للطيران المدني
General Authority of Civil Aviation
[Non-Text]
APPLICATION FOR AIR NAVIGATION SERVICE CERTIFICATE
<table><tr><td colspan="3">INSTRUCTIONS: Tick up the applicable items. Use extra sheets if required.</td></tr><tr><td colspan="2">1. ANS ORGANAZTION PARTICULARS</td><td>2. REASON FOR APPLICATION</td></tr><tr><td rowspan="2" colspan="2">A. OFFICIAL NAME OF ORGANIZATION</td><td>ORIGINAL APPLICATION</td></tr><tr><td>RENEWAL</td></tr><tr><td rowspan="2" colspan="2">B. PRINCIPAL BASE OF OPERATIONS</td><td>CHANGE IN SCOPE</td></tr><tr><td>AMENDMENT OF CERTIFICATE</td></tr><tr><td rowspan="2" colspan="2">C. OFFICIAL MAILING ADDRESS OF ANS ORGANAZATION:</td><td>CHANGE OF FACILITIES</td></tr><tr><td>Others (Specify):</td></tr><tr><td colspan="3"></td></tr><tr><td colspan="3">3. SERVICES APPLIED(Please strikethrough as required)</td></tr><tr><td>AIR TRAFFIC SERVICESGACAR PART 171INSTRUMENT FLIGHT PROCEDURE SERVICESGACAR PART 172</td><td></td><td>OPERATIONS MANUAL(S)(FOR ALL PARTS)</td></tr><tr><td>AERONAUTICAL TELECOMMUNICATIONS SERVICESGACAR PART 173</td><td></td><td>AIR TRAFFIC SERVICES PROCEDURES MANUALS(FOR PART 171)</td></tr><tr><td>AERONAUTICAL INFORMATION SERVICESGACAR PART 175</td><td></td><td>SAFETY MANAGEMENT SYSTEM MANUAL(S)(FOR PART 171, 172, 173 AND 175)</td></tr><tr><td>METEOROLOGY SERVICES FOR AIR NAVIGATIONSERVICES GACAR PART 179</td><td></td><td>SECURITY PROGRAM MANUAL(S)(FOR PART 171 AND 173)ORCOPY OF THE SECURITY AUTHORIZATION(ISSUED BY THE PRESIDENT) IF APPLICABLE</td></tr><tr><td>FLIGHT VALIDATION SERVICEGACAR PART 172</td><td></td><td>DETAILS OF MANAGEMENT PERSONNEL</td></tr><tr><td>FLIGHT INSPECTION SERVICEGACAR PART 173</td><td></td><td>DETAILS OF CONTRACTED ACTIVITIES(REFER GACAR 170.64)</td></tr><tr><td>OTHER (specify):</td><td></td><td>COPIES OF SUPPORTING INFORMATION NECESSARY TOMAKE CHANGES TO OPERATIONS SPECIFICATIONS(SPECIFY OPS-SPEC TO BE CHANGED)</td></tr><tr><td>LIST DETAILS OF ADDITIONAL INFORMATION PROVIDED WITHTHE APPLICATION:</td><td></td><td>A STATEMENT OF COMPLIANCE(COMPLIANCE CHECKLIST);</td></tr><tr><td></td><td></td><td>LETTER INDICATING WHEN THE APPLICANT WILL BE READYFOR THE DEMONSTRATION AND INSPECTIONS.</td></tr></table>
5. APPLICANT'S CERTIFICATION
I hereby certify that I have been authorized by the repair station identified in Block 1 to make this application and that statements and attachment hereto are true and correct to the best of my knowledge.
<table><tr><td></td><td></td><td></td><td></td></tr><tr><td>Date</td><td>Name &amp; Title</td><td>Authorized Signature</td><td></td></tr></table>
GACA-AVSES-ANS-F004
Rev: 5, Date: 16 Mar 25
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GACA
الهييه العامه للطيران المدني
General Authority of Civil Aviation
[Non-Text]
APPLICATION FOR AIR NAVIGATION SERVICE CERTIFICATE
6. RECORD OF ACTION (GACA USE ONLY)
Physical inspection (Attach report)
7. FINDINGS: (Identify by item number, include deficiencies found) (Attach report)
8. RECOMMENDATIONS
<table><tr><td colspan="4">A. APPLICANT WAS FOUND TO COMPLY WITH REQUIREMENTS OF APPLICABLE GACARs EXCEPT FOR DEFICIENCIES LISTED IN BLOCK 7</td><td>□</td></tr><tr><td colspan="4">B. ISSUE OPS-SPECS WITH RATING(S) APPLIED FOR ON APPLICATION (Except those listed in Block 7)</td><td>□</td></tr><tr><td colspan="4">C. OTHER Remarks (Attach Details)</td><td>□</td></tr><tr><td>Date</td><td>Name (Authorized Inspector)</td><td>Title</td><td colspan="2">Signature</td></tr><tr><td></td><td></td><td></td><td colspan="2"></td></tr><tr><td></td><td></td><td></td><td colspan="2"></td></tr></table>
GACA-AVSES-ANS-F004
Rev: 5, Date: 16 Mar 25
Page 2 of 2