Form KU 145-01

MINISTRY OF TRANSPORTATION
DIRECTORATE GENERAL OF CIVIL AVIATION
DIRECTORATE OF AIRWORTHINESS AND AIRCRAFT OPERATIONS
Karya Bld. 22nd Floor, Jl. Medan Merdeka Barat No. 8 Jakarta Pusat 10013 Phone: 62-21 3 0666!, 62-21 3 0666 Fa"s#$#le : 62-21 3 06663

APPLICATION FOR ORGANIZATION APPROVAL

%&''l#ed (or under )e'u*l#" o( +ndones#a ,#-#l &-#at#on .a(ety )e/ulat#on0 1. 2. 3. 4. Name of applicant Address of Head Office Location of Premises : : :

Scope of Approval Req ested !"ontin e on separate s#eet if necessar$%

&.

'#e Person( )#o )ill *e responsi*le to t#e +irector on *e#alf of t#e Or,ani-ation for ens rin, a satisfactor$ of operation accordin, to t#e req irement of t#ese re, lation Name . Post / alifications Si,nat re Specimen

0.

!a% '#e follo)in, f ll1time emplo$ees are nominated for approval as si,natories of lo, *oo2s( release certificates( test reports. 3nspection records( etc.( )it#in t#e scope of approval req ested. !"ontin e on separate s#eet if necessar$%. 4rief / alifications or A.5.6. Name +esi,nation A t#ori-ed to si,n licence Nr. :

!*% Approved Si,nator$ and 3nspection Stamp Record 4oard( f ll$ completed( is attacted( in respect of eac# emplo$ee nominated. 7. '#e follo)in, tests pilots )ill *e responsi*le for carr$in, o t fli,#t tests and certif$in, t#at t#e fli,#t c#aracteristics of t#e aircraft are satisfactor$( t#e a t#orit$ *ein, limited to t#e aircraft listed in t#eir '$pe Ratin,s and )it# )#ic# t#e$ c rrentl$ familiar. Name Licence Nr. 4rief / alifications

Rev. 16/09

8.

5aintenance f nction !if an$% contracted to o tside a,encies. !contin e on separate s#eet if necessar$%. Name Licence Nr. 4rief / alifications

9.

a. :e confirm #avin, o*tained copies of t#e follo)in, p *lications( and )e a)are or o r responsi*ilities nder t#ese req irements( e.,. : Rep *lics of 3ndonesia "ivil Aviation Safet$ Re, lation: Advisor$ circ lars( air)ort#iness directives( and ot#er civil air)ort#iness req irements. *. All man als of t#e compan$ are enclosed )it# t#is application in t#e form of q alit$ !inspections% man al;compan$ !A5O% man al ; ot#er c. '#e compan$<s facilities( s$stem of inspection( tec#nical direction and records compl$ )it# t#e appropriate c rrent "ivil Aviation Safet$ Re, lations( and )ill *e availa*le for inspection( as from ======================..=====. d. Remar2s

3 "ertif$ t#at t#e statements made *$ me on t#is Application are tr e( Place( ==============( ==============..

Si,nat re ======================== ===. >or +?"A official onl$

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! +?"A 3nspector