gaca_gov_sa · form · processed · 2 chunks
GACA اللغه العامه للطيران المدني General Authority of Civil Aviation [Non-Text] APPLICATION FOR AIRWORTHINESS CERTIFICATE (Initial/Renewal) I. AIRCRAFT DESCRIPTION (Refer to aircraft manufacturer's Data Plate) <table><tr><td>Registration Mark</td><td>Aircraft Builder's Name (Make)</td><td>Aircraft Model Designation</td><td>Max G. Weight (Kg)</td></tr><tr><td>Aircraft Serial No.</td><td>Engine Builder's Name (Make)</td><td>Engine Model Designation</td><td>Number Of Engines</td></tr><tr><td>APU Make/Model</td><td>Propeller Make/Model</td><td>Year of Mfg.</td><td>Aircraft IsNewUsed</td></tr></table> II. STANDARD CERTIFICATE CATEGORY (For Standard Certificate only) <table><tr><td>□ Normal</td><td>□ Utility</td><td>□ Transport</td><td>□ Commuter</td><td>□ Balloon</td><td>□ Acrobatic</td></tr></table> III. SPECIAL CERTIFICATE CATEGORY (For Special Certificate only) <table><tr><td colspan="10">□ Primary</td></tr><tr><td>□ Light Sport</td><td colspan="9">□ Airplane □ Power Parachute □ Weight shift control □ Glider □ Lighter than Air</td></tr><tr><td rowspan="2">□ Restricted</td><td colspan="9">□ Agriculture and Pest Control □ Aerial Survey □ Aerial Advertising □ Forest (Wildlife Conversation) □ Patrolling</td></tr><tr><td colspan="9">□ Weather Control □ Other (specify):</td></tr><tr><td rowspan="3">□ Experimental</td><td colspan="9">□ Research and Development □ Amateur Built □ Exhibition □ Air Racing □ Crew Training</td></tr><tr><td colspan="9">□ Market Survey □ To Show Compliance with GACA Regulations □ Operating LSA □ LSA, Kit Built</td></tr><tr><td colspan="9">□ Unnamed Aircraft □ Market Survey □ Crew Training □ Research/Development</td></tr><tr><td colspan="10">Reason For Application □ Initial Issue □ Renewal □ Amendment □ Request Period Yrs.</td></tr></table> IV. OWNER'S CERTIFICATION <table><tr><td colspan="4">Registered Owner (As shown on Certificate of Aircraft Registration)</td></tr><tr><td colspan="2">Name</td><td>Email</td><td>Phone</td></tr><tr><td colspan="4">Address</td></tr><tr><td colspan="4">Aircraft Certification Basis (Check applicable blocks and complete items as indicated)</td></tr><tr><td>□</td><td>Aircraft Specification or Type Certificate Data Sheet (Give No. And Revision No.)</td><td>□</td><td>Airworthiness Directives(Check If All Applicable AD's Complied with and Give Latest AD Number)</td></tr><tr><td>□</td><td>Aircraft Noise Chapter No.(Ref. ICAO Annex 16, Volume I)</td><td>□</td><td>Supplemental Type Certificate(List Number of Each STC Incorporated)</td></tr><tr><td colspan="4">Aircraft Operation and Maintenance Records</td></tr><tr><td>□</td><td colspan="2">Check If Records Are in Compliance with GACAR § 91.457</td><td>Total Airframe Hours (Enter for Used Aircraft Only)</td></tr><tr><td colspan="4">Certification: “I hereby certify that I am the owner (or his agent) of the aircraft described above: that the aircraft is registered in the Kingdom of Saudi Arabia in accordance with GACAR Part 47 and that the aircraft has been inspected and is airworthy and eligible for the airworthiness certificate requested”</td></tr><tr><td>Date of Application</td><td>Title</td><td>Name: (Print or Type)</td><td>Signature</td></tr><tr><td></td><td></td><td></td><td></td></tr></table> V. INSPECTION AGENCY VERIFICATION <table><tr><td colspan="4">The aircraft described above have been inspected and found airworthy by</td></tr><tr><td>□</td><td colspan="2">GACAR Part 121 Certificate Holder (Give Certificate No.)</td><td>□ Certificated Mechanic (Give Certificate No.)</td></tr><tr><td>□</td><td colspan="2">Certificated Repair Station (Give AMO Certificate No.)</td><td>□ Aircraft Manufacturer (Give name of firm.)</td></tr><tr><td colspan="2">Date</td><td>Name</td><td>Signature</td></tr><tr><td colspan="2"></td><td></td><td></td></tr></table> VI. GACA REPRESENTATIVE CERTIFICATION I find that the aircraft described in the Section above meets the requirements for the certification requests or the amendment of the Airworthiness Certificate <table><tr><td>Date</td><td>Title</td><td>Name</td><td>Signature</td></tr><tr><td></td><td></td><td></td><td></td></tr></table> GACA-AVSES-AIR-F006 Rev: 6, Date: 20 Apr 25 Page 1 of 1