Form SRG1746 "Application/Recommendation for the Issue of a National Airworthiness Review Certificate in Accordance With Bcar A3/B3-1" - United Kingdom

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Application /Recommendation for the Issue of a National
Airworthiness Review Certificate in accordance
with BCAR A3/B3-1
Note: A Recommendation can only be accepted from a Continuing Airworthiness Management organisation
(CAMO) holding a BCAR A8-25 (CAMO) approval of BCAR A8-15 (M3) approved organisation and having the
subject aircraft type within its scope.
Please complete this form online (preferred method) then print, sign and submit as instructed.
Alternatively, print, then complete in BLOCK CAPITALS using black or dark blue ink.
Please complete either section 1 a) or section 1 b). For all Registered Companies, please complete section 1 b) only.
APPLICANT DETAILS to be completed by: Owner
Operator
Lessee
(Please tick as applicable)
1. APPLICANT DETAILS (The Applicant is the person responsible for payment of CAA charges)
a)
Individual (including sole traders and partnerships)
Title: ................
Forename: ......................................................
Surname: ............................................................
Address: ............................................................................................................................................................................
........................................................................................
Postcode: ............................................................................
Telephone: ......................................................................
Fax: .....................................................................................
E-mail: ............................................................................
Mobile Telephone: ...............................................................
Trading Name: (if applicable) ............................................................................................................................................
Website address: ..............................................................................................................................................................
In the case of a partnership, please complete details of all partners. Continued on a separate sheet
or b)
A Company
Registered Company Name (in full): .................................................................................................................................
Registered Company Number: ..........................................................................................................................................
Country of Company Registration: ................................................
Registered Office Address: ...............................................................................................................................................
.......................................................................................................................
Postcode: ............................................
Telephone: ......................................................................
Fax: .....................................................................................
E-mail: ...............................................................................................................................................................................
Trading Name: (if applicable) ............................................................................................................................................
Trading Address (primary site): .........................................................................................................................................
.......................................................................................................................
Postcode: ............................................
Website address: ..............................................................................................................................................................
This application will be considered in respect of and, if appropriate, granted to, the Company Name as registered
under the Company Number provided on this form.
2. APPLICATION
I wish to apply for:
The issue of a National Airworthiness Review Certificate based upon the certification and recommendation given in
Section 5.
The CAA to conduct an Airworthiness Review in accordance with BCAR Chapter A8-25 paragraph 10 and to issue
the National Airworthiness Review Certificate
Is the aircraft operated under an AOC? Yes
No
Page 1 of 5
Form SRG 1746 Issue 01 19032012
Application /Recommendation for the Issue of a National
Airworthiness Review Certificate in accordance
with BCAR A3/B3-1
Note: A Recommendation can only be accepted from a Continuing Airworthiness Management organisation
(CAMO) holding a BCAR A8-25 (CAMO) approval of BCAR A8-15 (M3) approved organisation and having the
subject aircraft type within its scope.
Please complete this form online (preferred method) then print, sign and submit as instructed.
Alternatively, print, then complete in BLOCK CAPITALS using black or dark blue ink.
Please complete either section 1 a) or section 1 b). For all Registered Companies, please complete section 1 b) only.
APPLICANT DETAILS to be completed by: Owner
Operator
Lessee
(Please tick as applicable)
1. APPLICANT DETAILS (The Applicant is the person responsible for payment of CAA charges)
a)
Individual (including sole traders and partnerships)
Title: ................
Forename: ......................................................
Surname: ............................................................
Address: ............................................................................................................................................................................
........................................................................................
Postcode: ............................................................................
Telephone: ......................................................................
Fax: .....................................................................................
E-mail: ............................................................................
Mobile Telephone: ...............................................................
Trading Name: (if applicable) ............................................................................................................................................
Website address: ..............................................................................................................................................................
In the case of a partnership, please complete details of all partners. Continued on a separate sheet
or b)
A Company
Registered Company Name (in full): .................................................................................................................................
Registered Company Number: ..........................................................................................................................................
Country of Company Registration: ................................................
Registered Office Address: ...............................................................................................................................................
.......................................................................................................................
Postcode: ............................................
Telephone: ......................................................................
Fax: .....................................................................................
E-mail: ...............................................................................................................................................................................
Trading Name: (if applicable) ............................................................................................................................................
Trading Address (primary site): .........................................................................................................................................
.......................................................................................................................
Postcode: ............................................
Website address: ..............................................................................................................................................................
This application will be considered in respect of and, if appropriate, granted to, the Company Name as registered
under the Company Number provided on this form.
2. APPLICATION
I wish to apply for:
The issue of a National Airworthiness Review Certificate based upon the certification and recommendation given in
Section 5.
The CAA to conduct an Airworthiness Review in accordance with BCAR Chapter A8-25 paragraph 10 and to issue
the National Airworthiness Review Certificate
Is the aircraft operated under an AOC? Yes
No
Page 1 of 5
Form SRG 1746 Issue 01 19032012
3. AIRCRAFT DETAILS
Registration G ...........
Type: ............................... Serial No:.........................
MTOW (kg)........................................
Engine Type Designation(s)
Serial No(s)
Propeller Type Designation(s) Hub& Blade
Propeller Serial
No.
Type
Hub
Blade
APU Type:
Serial No:
Total aircraft hours flown since manufacture to 31 December prior to this issue: .......... associated flight cycles:.................
Document return address: ......................................................................................................................................................
4. COMPLIANCE STATEMENT
To be completed by the person completing the certification statement in box 5. If any of the items below cannot be
confirmed please contact your CAA local regional office.
(
)
Please Tick
(a) It is confirmed that to satisfy the requirements for a BCAR A3/B3-1 airworthiness review of an aircraft, a full
documented review of the aircraft records has been carried out so that we are satisfied as to the matters specified
in BCAR A8-25 (10.1)
(b) A physical survey of the aircraft in accordance with BCAR A8-25 (10.3) has been satisfactorily completed
and any defects have been appropriately addressed.
(c) Place of document review: ...........................................................................
Date of document review: ....................
Place of physical survey: ..............................................................................
Date of physical survey:.......................
Name and licence number of BCAR Section L/Part 66 Licence holder assisting (if applicable).........................................
(d) CAA Approved Maintenance Programme reference:..........................................................
Issue/amendment:.............
(e) The aircraft complies with the latest revision of its type design approved/accepted by the CAA
(Please Tick)
(f) Aircraft Specification/TCDS: ............................
Revision/issue/edition number: ....................................................
(g) Aircraft Noise Certificate No: ................................................
(Corresponding to the current configuration of the aircraft, and in compliance with Part-21, Subpart l or BCAR A8-21, as
applicable)
(h) Flight Manual is applicable for the aircraft configuration
(Please Tick)
Or
Aircraft is operated under Operating Limitations document
(Please Tick)
Flight Manual/Operating Limitation document reference and latest revision status are:
Reference: ..................................................
Revision Status: ........................................................................................
(i) The current mass and balance statement reflects the configuration of the aircraft and is valid
(Please Tick)
Mass and Balance Statement dated: ......................................................... Reference: ...................................................
(j) All modifications and repairs have been carried out and are approved according to BCAR A8-8, A8-21 or Part 21, as
applicable.
(k) Aircraft is subject to flight test at:
(Please Tick ) (1Year)
(3Year)
or (Fleet Programme)
Date of last satisfactory Flight Test: ................
Aircraft tested to AFTS: .............................
Issue: ......................
(l)
All applicable mandatory requirements have been applied/
Country
Up to bi-weekly/AD
registered
number/issue/date
Aicraft State of Design Airworthines Directives
Engine State of Design Airworthiness Directives
Propeller State of Design Airworthiness Directives
Published EASA Airworhiness Directives
Equipment State of Design Airworthiness Directives
CAA Mandatory Requirements for Airworthiness CAP 747
United Kingdom
Page 2 of 5
Form SRG 1746 Issue 01 19032012
5. CERTIFICATION
Recommendation for the issue of an Airworthiness Review Certificate
(a)
Certification Statement for BCAR A8-15 Approved Organisation use
Pursuant to CAP 553 British Civil Airworthiness Requirements (BCAR) Section A, it is certified that the organisation
below, being approved in accordance with BCAR A8-15, has successfully performed an Airworthiness Review in
accordance with BCAR A3/B3-1 and recommends that a National Airworthiness Review Certificate be issued with a
validity period of twelve months in respect of the aircraft identified in this document.
(b)
Certification Statement for BCAR A8-25 Approved Organisation use
Pursuant to CAP 553 British Civil Airworthiness Requirements (BCAR) Section A, it is certified that the person below,
being an approved person in accordance with BCAR A8-25 has successfully performed an Airworthiness Review in
accordance with, BCAR A3/B3-1 and recommends that a National Airworthiness Review Certificate be issued with a
validity period of twelve months in respect of the aircraft identified in this document.
Name of Approved Organisation: .......................................................
Recomendation Date: ....................................
Approval Reference : ......................................
Company/Authorisation No./Licence No.: ....................................
Signed: ...........................................................
Full name of signatory.: ................................................................
6. SUBMISSION INSTRUCTIONS
When you have completed this Form, please send it together with the appropriate fee to:
Applications & Approvals
CAA, Aviation House
Gatwick Airport South
West Sussex
RH6 0YR
E-mail:aanda@caa.co.uk
If you are not the Director or Company Secretary and have been authorised to sign the application form on behalf of
the Company, please enclose proof of that authority.
7. CHARGES
The charge(s) required as calculated in accordance with the CAA Airworthiness Scheme of Charges (published in CAA
Official Record Series 5) (www.caa.co.uk/ors5) to be paid on application are enclosed herewith.
NB: This application will not be processed until the applicable fees have been received.
Provided correct fees are included, confirmation will be shown on www.caa.co.uk/ginfo within 5 working days and
applicable certificates posted.
Total charges included are: £ ..............................
IMPORTANT NOTES:
Additional Charges: Where the cost of the CAA investigations exceeds the application charge payable, the
applicant shall pay additional charges to recover those excess costs incurred by the CAA in accordance with the
Scheme of Charges.
Overseas Visits: If a Member or employee of the CAA is required to travel overseas in respect of this application
you are advised to read the CAA Scheme of Charges to which this application relates and the section entitled
'Additional charge where functions are performed abroad'. All expenses incurred in pursuance of this application by
virtue of travelling overseas will be payable by the applicant on demand.
Withdrawal/Cancellation of Approval: In the event that this application is withdrawn by the applicant, a
cancellation charge may be levied. The cancellation charge reflects the work carried out by the CAA on behalf of the
applicant up to the point of cancellation. Please see the CAA Refunds Policy at
www.caa.co.uk/refunds
for more
information. Where sufficient funds remain from the original application charge, this charge will be deducted from any
refund made in respect of the application following cancellation.
Page 3 of 5
Form SRG 1746 Issue 01 19032012
8. FINANCIAL DECLARATION
I hereby declare that to the best of my knowledge the particulars entered on this application are accurate.
I enclose the charges payable on application in accordance with the Scheme of Charges (www.caa.co.uk/ors5).
I agree to pay any additional charges which may become payable in respect of this application under the Scheme of
Charges.
Name of Applicant: ............................................................................................................................................................
1 a), 1 b) or 1 c)
(as shown in
)
Signature of Applicant
1 a)
: ...............................................................................................................................
(named in
)
or Signature of Authorised Representative
1 b) or 1 c)
: ........................................................................................
(named in
)
Date: ........................................
FALSE REPRESENTATION STATEMENT
It is an offence to make, with intent to deceive, any false representation for the purpose of procuring the grant, issue,
renewal or variation of any certificate, licence, approval, permission or other document. Persons doing so render
themselves liable, on summary conviction, to a fine not exceeding the statutory maximum (currently £5000, or in Northern
Ireland £2000) and on conviction on indictment to an unlimited fine or imprisonment for a term not exceeding two years or
both.
CAA USE ONLY
Applicant’s name ...............................................
Date of application .....................
The Civil Aviation Authority has:
a)
Issued a National Airworthiness Review Certificate in accordance with British Civil Airworthiness
Requirements (BCAR) Section A3/B3-1 (10), in accordance with the recommendation in section 5, valid
from the issue date below in respect of the aircraft identified in this document.
Or
Pursuant to British Civil Airworthiness Requirements (BCAR) Section A/3/B3-1(10) it is certified that the
CAA staff member below being an authorised person in accordance with BCAR A3/B3 (10.2.1 and 10.3.1)
b)
has successfully performed an Airworthiness Review in accordance with BCAR A-25 and issued a National
Airworthiness Review Certificate with a validity period of 12 months in respect of the aircraft identified in
this document.
Or
Issued a Certificate of Airworthiness and National Airworthiness Review Certificate in accordance with
c)
British Civil Airworthiness Requirements (BCAR) Section A3/B3-1 (9) respect of the aircraft identified in
this document
Date of Review: ............................... Place of Issue : ......................
Time of Issue*:.................................................
C of A Number: ............................... Issue Date: ............................
CAA Stamp Number: . .......................................
ARC Number: .................................. Issue Date: ............................
Expirty Date:...................................................
Noise Certificate Number: .......................................
Issue Date: .................................
Department: ....................................................................
Issue Date: ..........................................................................
Job No: ............................................ Folio No: ............
CAA Account Number:........................................................
Nominal Code: ...........................
Cost Centre: .................................
Date received. .........................................
If payment is received by cheque, attach a copy to this application form.
The sum of £ ..............................
has been received by: ...............................................
Date: ..................................
Amount paid by:
Cheque
Cash
Card
Electronic Transfer*
£ ..................................
£.........................
£ ..............................
£....................................
* Receipt of Electronic Transfer to be verified by Treasury.
Cheque drawn against account of: ....................................................................................................................................
Bank Account No: ..........................................................
Sort Code: ...........................................................................
Page 4 of 5
Form SRG 1746 Issue 01 19032012
9 PAYMENT DETAILS
a)
Payment type (please tick your chosen method of payment).
Visa
Mastercard
Debit Card
Cheque/Banker’s Draft
Electronic Transfer
Cash
(max. £2000)
(max. £200)
We do not accept American Express, Diners Club or JCB cards. Please do not send cash by post.
b)
Bank Details (for payment by Cheque/Banker’s Draft)
Cheques or Postal Orders should be made payable to 'Civil Aviation Authority'.
Please write the CAA Application Form No. on the reverse of your cheque.
Please note that any refund applicable will be paid directly to the bank account stated below by BACS transfer.
Name in which Bank Account held: ..................................................................................................................................
Account Number: ...........................................................
Sort Code: .....................................................................
If overseas: IBAN Number: .........................................
Swift Code: ....................................................................
c)
CAA Bank Account Details (if paying by Electronic Transfer)
National Westminster Bank plc
Bloomsbury Parr’s Branch
Account Name: Civil Aviation Authority
PO Box 158
Account Number: 36029769
214 High Holborn
Sort Code: 60-30-06
London
Swift Code: NWBK GB 2L
WC1V 7BX
IBAN: GB90 NWBK 6030 0636 0297 69
Please supply the following information:
Amount: £ ..............................................
BACS/CHAPS Reference*: .........................................................
* When making an electronic transfer please instruct your bankers to quote the CAA Application Form number
followed by the application date in the description field (i.e. SRG 1746ddmmyyyy).
Payer: .............................................................................
Date of Transfer...............................................................
d)
Card Details (for payment by Credit/Debit Card)
Card number:
/
Expiry date:
Security Code (last 3 digits on signature strip on reverse of card)
Debit cards only:
Start date:
Amount: £ ....................................
/
Issue No:
(if applicable)
Name (as written on card): ................................................................................................................................................
(BLOCK CAPS)
Full postal address of card holder: .....................................................................................................................................
.......................................................................................................................................
Postcode: .................................
Card holder’s signature: ................................................................................................
Please tick box if paying with Company Card
Company Name: ............................................................................
This information is provided at the applicant’s risk and will be used by the CAA for this payment only and will not
be used for any other purpose.
Page 5 of 5
Form SRG 1746 Issue 01 19032012
Page of 5