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MINISTRY OF TRANSPORTATION

DIRECTORATE GENERAL OF CIVIL AVIATION


Office Complex Soekarno-Hatta International Airport, C3 St., Tangerang, Banten- Indonesia
Telp.: (+6221) 225 66288, (+6221) 256 08887 Fax. : (+6221) 225 66399
Website : hubud.dephub.go.id; e-mail: daao_dgca@dephub.go.id

APPLICATION FOR AIRWORTHINESS CERTIFICATE


I. AIRCRAFT DESCRIPTION
1. NATIONALITY AND 2. AIRCRAFT BUILDER’S/MANUFACTURER 3. AIRCRAFT MODEL 4. SERIAL NO. 5. YEAR OF MFG.
REGISTRATION MARKS

6. ENGINE 7. ENGINE MODEL 8. ENGINE SERIAL NO. 1) 2) 3) 4)


BUILDER’S/MANUFACTU
RER
9. PROPELLER 10. PROPELLER MODEL 11. PROPELLER SERIAL NO. 1) 2) 3) 4)
BUILDER’S
MANUFACTURE
12. MAXIMUM TAKE-OFF WEIGHT (LBS.)
0 – 15.000 15.001 – 100.000 100.001 – 200.000 200.001 - up

II. CERTIFICATION REQUESTED


APPLICATION IS HEREBY MADE FOR: (Check Applcable Item)
STANDARD AIRWORTHINESS CERTIFICATE NORMAL COMMUTER TRANSPORT UTILITY ACROBATIC BALLOON
A 1 (Indicate Category)
SPECIAL CLASS AIRSHIP OTHER NON-CONVENTIONAL AIRCRAFT
B 2 SPECIAL AIRWORTHINESS CERTIFICATE (Check Appropiate Item)
a LIMITED
LIGHTER
b LIGHT SPORT (Indicate Class) AIRPLANE POWER PARACHUTE WEIGHT-SHIFT CONTROL GLIDER
THAN AIR
1 CLASS I.
c PROVISIONAL (Indicate Class)
2 CLASS II.
AERIAL
1 AGRICULTURE & PEST CONTROL 4 AERIAL SURVEYING 6
ADVERTISING
d RESTRICTED
(Indicate Operation To Be Conducted) 2 FOREST 5 PATROLING 7 OTHERS
3 WEATHER CONTROL
1 RESEARCH AND DEVELOPMENT 4 AMATEUR BUILT 7 EXHIBITION
e EXPERIMENTAL 2 AIR RACING 5 CREW TRAINING 8 MARKET SURVEY
(Indicate Operation To Be Conducted)
3 TO SHOW COMPLIANCE WITH CASR 6 OPERATING LIGHT-SPORT
1 FLYING AIRCRAFT FOR REPAIRS, ALTERATION, MAINTENANCE OR STORAGE
SPECIAL FLIGHT PERMIT 2 DELIVERING OR EXPORT
(Indicate Operation To Be Conducted, then 3 PRODUCTION FLIGHT TESTING
f
Complete Section V or VI as applicable on 4 EVACUATE FROM AREA OF IMPENDING DANGER
Reverse Side) 5 CUSTOMER DEMONSTRATION FLIGHT IN NEW PRODUCTION AIRCRAFT
6 OPERATION IN EXCESS OF MAXIMUM CERTIFICATED TAKE-OFF WEIGHT
C 3 MULTIPLE AIRWORTHINESS CERTIFICATE (Check Above “Restricted Operation” And “Limited” As Applicable)
III. OWNER CERTIFICATION
A. REGISTERED OWNER
NAME ADDRESSES

B. APPLICANT
NAME ADDRESSES

C. AIRCRAFT CERTIFICATION BASIS


1 AIRCRAFT SPECIFICATION OR TYPE CERTIFICATE DATA SHEET 2 AIRWORTHINESS DIRECTIVE (GIVE THE LATEST AD NO.)

3 SUPPLEMENTAL TYPE CERTIFICATE (LIST THE EMBODIED STC)

D. AIRCRAFT OPERATION AND MAINTENANCE RECORDS


1. CHECK IF RECORD IN 2. TOTAL FLIGHT HOURS – 3. EXPERIMENTAL ONLY (ENTER HOURS FLOWN SEEN LAST CERT. ISSUED OR RENEW )
COMPLIANCE WITH CASR 91.417
E. CERTIFICATION – I here by certify that I am the owner/builder (manufacturer)/operator of the aircraft described above that the aircraft is registered
with the Directorate General of Civil Aviation in accordance with Article 24 and 25 of the Aviation Act No. 1 of 2009 and applicable Civil Aviation
Safety Regulations and that the aircraft has been inspected and is airworthy and eligible for the airworthiness certificate r equested.
DATE OF APPLICATION NAME AND TITLE SIGNATURE

IV. INSPECTION AGENCY VERIFICATION (Complete the section only if CASR 21.183 (d) applies)
A. THE AIRCRAFT DESCRIBED ABOVE HAS BEEN INSPECTED AND FOUND AIRWORTHY BY:
AIRCRAFT OPERATOR CERTIFICATE HOLDER NO.: APPROVED MAINTENANCE ORGANIZATION HOLDER NO:
AIRCRAFT MANUFACTURER (GIVE NAME OR FIRM) OTHER:
DATE OF APPLICATION NAME AND TITLE SIGNATURE

DGCA Form No. 21-21 (Oct 2017) Page: 1 of 2


V. DGCA CERTIFICATION
I find that the aircraft described in Section I meets the requirements for the certificate requested/amendment or modification of this current
airworthiness certificate.
DATE DGCA INSPECTOR’S SIGNATURE

VI. PRODUCTION FLIGHT TESTING


A. MANUFACTURER
NAME ADDRESS

B. PRODUCTION BASIS
PRODUCTION CERTIFICATE (GIVE PRODUCTION CERTIFICATE NUMBER)
TYPE CERTIFICATE
OTHER
C. GIVE QUANTITY OF CERTIFICATES REQUIRED FOR OPERATING NEEDS
DATE OF APPLICATION NAME AND TITLE SIGNATURE

VII. SPECIAL FLIGHT PERMIT PURPOSE OTHER THAN PRODUCTION FLIGHT TEST
A. DESCRIPTION OF AIRCRAFT
REGISTERED OWNER ADDRESS

B. DESCRIPTION OF FLIGHT
1. FROM 2. TO

3. VIA 4. DEPARTURE DATE 5. DURATION

C. CREW REQUIRED TO OPERATE THE AIRCRAFT AND ITS EQUIPMENT


PILOT CO-PILOT FLIGHT ENGINEER OTHER (SPECIFY)
D. THE AIRCRAFT DOES NOT MEET THE APPLICABLE AIRWORTHINESS REQUIREMENTS AS FOLLOWS:

E. THE FOLLOWING RESTRICTIONS ARE CONSIDERED NECESSARY FOR SAFE OPERATIONS

F. CERTIFICATION – I hereby certify that I am the owner/builder (manufacturer)/operator of the aircraft described above that the aircraft is registered
with the Directorate General of Civil Aviation in accordance with Article 24 and 25 of the Aviation Act No. 1 of 2009 and applicable Civil
Aviation Safety Regulations and that the aircraft has been inspected and is safe for flight described.

DATE NAME AND TITLE SIGNATURE


VIII. AIRWORTHINESS DOCUMENTATIONS (DGCA USE ONLY)
(Tick the followings to indicate completeness and correctness)
A. OPERATING LIMITATIONS AND MARKING F. THIS INSPECTION RECORDED IN AIRCRAFT RECORD
B. CURRENT OPERATING LIMITATIONS ATTACHED G. STATEMENT OF CONFORMITY, DGCA FORM No. 21-07
C. DATA DRAWING, PHOTOGRAPH, ETC. (ATTACHED AS REQUIRED) H. PREVIOUS CERTIFICATE OF AIRWORTHINESS ISSUED ON:
D. CURRENT WEIGHT AND BALANCE INFORMATION AVAILABLE IN AIRCRAFT I. CURRENT CERTIFICATE OF AIRWORTHINESS ISSUED ON:
E. MAJOR REPAIR AND ALTERATION DGCA FORM No. 43-337(ATTACHED) J. LIGHT SPORT AIRCRAFT STATEMENT OF COMPLIANCE

DGCA Form No. 21-21 (Oct 2017) Page: 2 of 2