APPLICATION FOR RENEWAL OF A CERTIFICATE OF …

1 CA 21-03 21 JULY 2017 Page 1 of 2 Section/division: AIRWORTHINESS: AIRCRAFT INSPECTION & REGISTRATION Form Number: CA 21-03 Telephone number: 011-545-1000 Fax Number: 086 643 3511 Physical address: Ikhaya Lokundiza, 16 Treur Close, Waterfall Park, Bekker Street, Midrand, Gauteng Postal address: Private Bag X73, Halfway House 1685 Website: DETAILS OF BANK ACCOUNT FOR PAYMENT OF PRESCRIBED FEE Bank: Standard Bank of SA Ltd Branch: Brooklyn, Pretoria Branch Code: 011245 Account Number: 013007971 COMPULSORY CLIENT PAYMENT CODE (to be completed on deposit slip) Service/transaction Over the counter payments EFT, Internet, Wire, Electronic payments Fees: See CAR Part APPLICATION FOR RENEWAL OF A CERTIFICATE OF AIRWORTHINESS Please note the following conditions: 1. APPLICATION shall be submitted 60 days prior to C of A expiry date refer to CAR (a) (1).

2 2. In terms of CAR SA-CATS -The record of work accomplished may be submitted by: (a) recording relevant data on the applicable annual maintenance review report form; OR (b) attaching relevant data certified by the appropriately rated AMO, to the applicable annual maintenance review report form; OR (c) attaching copies of the appropriate logbook pages to the applicable annual maintenance review report form.. 3. 90 days grace period is now covered in the regulations Refer to CAR 12(a) (4) failure to comply will warrant action in terms of CAR 4. In terms of CAR SA-CATS - If an aircraft is unserviceable at the time of the APPLICATION for the RENEWAL of the CERTIFICATE of Airworthiness, the owner/operator may lodge an APPLICATION for such RENEWAL together with appropriate fee as prescribed by Part 187.

3 Once the outstanding documentation has been submitted to the Director, within a period of 365 days since the expiry date of the CERTIFICATE of Airworthiness, the CERTIFICATE of Airworthiness shall be processed. Furthermore, if the information provided demonstrates that the aircraft is serviceable, the Director shall process the APPLICATION for the RENEWAL . AIRCRAFT REGISTRATION MARKS Z - 1. CURRENCY FEE PAYMENT DESCRIPTION R c Currency year 2016 - 2017 Currency year 2017 - 2018 TOTAL PAYABLE 2. CONTACT DETAILS OF AIRCRAFT MAINTENANCE ORGANIZATION (AMO) Name of Organization AMO number Name of Accountable person Telephone number Cell phone number Fax number e-mail address 3. DETAILS OF THE AIRCRAFT OWNER Name of aircraft Owner Postal address Postal code Telephone number Fax number E-mail address 4. DESCRIPTION OF AIRCRAFT Manufacturer Model designation Airframe serial number Type CERTIFICATE number Date of manufacture State of manufacture 5.

4 DESCRIPTION OF ENGINE(S) Manufacturer Model designation(s) CA 21-03 21 JULY 2017 Page 2 of 2 Serial number(s) 1. 2. 3. 4. 6. DESCRIPTION OF PROPELLER(S) Manufacturer Model designation(s) Serial number(s) 1. 2. 3. 4. 7. SUPPORTING DOCUMENTATION 1) APPLICATION form completed in full accompanied by proof of payment 2) Mass and balance Latest report 3) Valid Radio station License 4) Flight Folio (Last record indicating total airframe hours/cycles); 5) CERTIFICATE of Release to Service (CRS) (Current Valid Release to Service) 8. CA 43-02/03/05 Form Or Certified Data Or Logbook ( previous 12 months record) (Less than 10 pages only) 8 A CA 43-02/03/05 form correctly completed and up to date by listing appropriate data on the form OR Attaching CA 43-02/03/05 and relevant data certified by an appropriately rated AMO OR Attaching CA 43-02/03/05 and copies of the appropriate logbook pages 8 B Submission covered in 8 A shall include the following list: (1) Scheduled maintenance checks carried out (Since last C of A RENEWAL ) (2) Serialised list of components replaced and/or fitted (Since last C of A RENEWAL ); (3) Ads, SBs and all relevant Continuing Airworthiness maintenance performed (Since last C of A RENEWAL ); (4) List of Modifications and major repairs embodied (Since last C of A RENEWAL ).

5 Airworthiness CERTIFICATE category required (Please tick applicable box) Standard Restricted Experimental Airworthiness Design Standard Categories (Please tick applicable box) Note : Info below can be obtained from the TCDS Normal Normal category (Rotorcraft) Utility Transport category (Rotorcraft) Acrobatic Non-rigid airship Commuter (Aeroplanes) Manned free balloon Transport Category (Aeroplanes) Other categories(specify) 9. DECLARATION I hereby declare that I am, or have applied to be, the registered owner/operator (or the agent acting on behalf of the registered owner/operator) of the aircraft described in paragraph 3 and to the best of my knowledge and belief, the particulars contained in this APPLICATION are accurate in every respect and show compliance with Part 21 of the Civil Aviation Regulations, 2011, as amended.

6 SIGNATURE OF APPLICANT / OWNER / AGENT NAME IN BLOCK LETTERS DATE FOR OFFICIAL USE ONLY APPLICATION ACCEPTED APPLICATION NOT ACCEPTED SIGNATURE OF INSPECTOR NAME IN BLOCK LETTERS DATE