Form Number: AIRWORTHINESS Email: [email protected] 011-545-1000 Ikhaya Lokundiza, 16 Treur Close, Waterfall Park, Bekker Street, Midrand, Gauteng Section/division: Telephone number: Physical address: Postal address: Bank: Standard Bank of SA Ltd Service/transaction Fees: See CAR Part 187.00.10 CA 91-02 Website: www.caa.co.za Private Bag X73, Halfway House 1685 DETAILS OF BANK ACCOUNT FOR PAYMENT OF PRESCRIBED FEE Branch: Brooklyn, Pretoria Branch Code: 011245 Account Number: 013007971 COMPULSORY CLIENT PAYMENT CODE (to be completed on deposit slip) Over the counter payments EFT, Internet, Wire, Electronic payments 406 MHZ ELT REGISTRATION FORM Aircraft Registration Z - ELT INFORMATION (Beacon ID (Unique Identifier Number)) Enter old beacon unique code (change of beacon registration) ELT Manufacturer Model/Type Beacon Part no. Serial number of beacon Type of ELT: Automatic fixed (AF) Automatic Portable (AP) Survival (S) Automatic Deployable (AD) Please mark the appropriate block New ELT Registration Change of ELT ownership Change of ELT information 1. OWNER / OPERATOR INFORMATION Name Postal address Postal code Telephone: (Home) (Work) Cell phone number Fax number Email 2. AIRCRAFT INFORMATION Manufacturer Model designation Airframe serial number Aircraft Colour Seating capacity Principal Airport Type of operation / usage: General aviation Commercial Military Other Radio Equipment: VHF CA 91-02 HF MF SSB 3 JUNE 2014 Other Page 1 of 2 3. EMERGENCY CONTACTS Name of Primary contact (24-Hour emergency) Telephone (Home) (Work) (Cell) (Other) Name of Alternate 24-hour emergency contact Telephone (Home) (Work) (Cell) (Other) SIGNATURE OF APPLICANT / OWNER / AGENT NAME IN BLOCK LETTERS DATE FOR OFFICIAL USE ELT REGISTERED ELT NOT REGISTERED COMMENTS: SIGNATURE OF AIRWORTHINESS INSPECTOR CA 91-02 NAME IN BLOCK LETTERS 3 JUNE 2014 DATE Page 2 of 2
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