Application Form For A Certificate Of Airworthiness
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1APPLICATION FOR A CERTIFICATE OF AIRWORTHINESS
A. DETAILS OF AIRCRAFT:
1. Registration Mark: P4- _______________ (followed by three letters)
2. Aircraft Manufacturer: _________________________________________________________________________________________________________
3. Model: ______________________________________________________________
8. Serial No.: ___________________________________________
4. Engine Manufacturer: _____________________________________________
9. Engine model: ______________________________________
5. Propeller Manufacturer: __________________________________________ 10. Propeller model: ___________________________________
6. Number of approved passenger seats: __________________________ 11. Type Certificate No.: _______________________________
7. Aircraft is:
New
Used Airframe hours: _________________________________ Cycles: _______________________________
Renewal
B. CERTIFICATION REQUESTED:
1.
Standard Certificate of Airworthiness Category:
Transport
Normal
Utility
Acrobatic
Manned Balloon
Glider
2. Classification of usage of the aircraft:
Private
Commercial
3.
Export Certificate of Airworthiness (if applicable)
4.
Interim Certificate of Airworthiness
Restricted
Unrestricted
(For a special flight permit application please complete DCA Form INS-4.034)
1. Available dates: ________________________________________________________________________________________________________________
C. DETAILS OF AIRCRAFT INSPECTION:
2. Location (city, country and airport): _________________________________________________________________________________________
3. Details of nominated person responsible to present the aircraft and its record for inspection:
4. Name: __________________________________________________________________________________________________________________________
Tel: __________________________________________________________ Email: _________________________________________________________
5. Is the aircraft in maintenance:
Yes
No
If yes, indicate estimated release date: _________________________________
D. DETAILS OF AIRCRAFT MAINTENANCE:
1. Has the aircraft been stored:
Yes
No
If yes, indicate for how long: ____________________________________________
2. Nominated person/organization performing for line maintenance: ______________________________________________________
3. Nominated maintenance organization performing base maintenance: ____________________________________________________
4. Nominated person/organization performing continuing airworthiness: __________________________________________________
E. DECLARATION:
By signing the application I hereby declare, to the best of my knowledge, that all information provided is truthful, that
the records are organized in accordance with AMC-012, and that the aircraft is in an airworthy condition and eligible
for the Certificate of Airworthiness being applied for.
Name undersigned: ____________________________________________
Company: _______________________________________________________
Position in company: __________________________________________
Signature of Applicant: ________________________________________
Date (Day-Month-Year): __________________________
Form INS-4.009
Page 1 of 1
Rev. 12 – Jan 2014
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