Form 1155 Application for Grant, Change or

Re-issue of a Delegation or Appointment

Guidelines Refer to: CAR 6, CASR 11.260, 201.001

Form 1155 06/2016 Grant, Change or Re-Issue of a Delegation or Appointment – Guidelines Page i of v

Privacy Statement Any personal information you provide to CASA is protected by the Privacy Act 1988 (Cth). CASA can only collect, use and disclose that information in accordance with that Act. CASA will use the information collected in this form for purposes associated with performing its functions under the Civil Aviation Act 1988, the Airspace Act 2007, the Aviation Transport Security Act 2004 or the regulations made under those Acts. For full details on how CASA collects, protects and uses personal information, please refer to CASA’s Privacy Policy.

These guidelines are designed to assist you to complete the application process for the initial issue or variation or re-issue of an instrument of appointment or delegation.

It is the applicant’s responsibility to apply for CASA approval only if they have an operational requirement for the approval and can demonstrate compliance with all the relevant regulatory requirements. Please carefully read this document and any relevant Acceptable Means of Compliance, Guidance Material or Advisory Circular issued by CASA and available on the CASA website www.casa.gov.au.

Who uses this form?

This form should be used if you are:

1. Applying to be appointed as an authorised person for the purpose of any of the following provisions of the Civil Aviation Regulations 1988 (CAR) or the Civil Aviation Safety Regulations 1998 (CASR):

CAR 29A - conduct a welding examination CAR 42M - approve a system of maintenance CAR 42R - approve changes to a system of maintenance CAR 42ZC(7) - authorise another person to carry out maintenance on a Class A aircraft CAR 262AP(5) - authorise an experimental aircraft to be operated over the built up area of a city or town CAR 262AP(6) - authorise an experimental aircraft to be operated other than by day and under the V.F.R. CASR 21.176 - issue a Certificate of Airworthiness CASR 21.190 - approve manufacture of and conduct inspections on an ABAA aircraft CASR 21.195A - issue an experimental certificate CASR 21.200 - issue a Special Flight Permit

CASR 21.324 - issue an export airworthiness approval (Export Certificate of Airworthiness or authorised release certificate)

2. Applying to be delegated CASA's powers and functions under any of the following regulations of the Civil

Aviation Regulations 1988:

CAR 37 - approve a permissible unserviceability (PU) or minimum equipment list (MEL) CAR 42ZC(6) - authorise a person to carry out inspections using non-destructive testing methods Applicants are required to complete and submit all parts for the application to be acceptable to CASA.

About this application form and the application process

Applicants can complete the PDF version of this application form electronically, however, the application form will need to be printed, signed and submitted to CASA by email (scanned), fax or post.

Note: CASA may refuse to consider an application or to consider it further while there are requirements that the applicant has not complied with (CASR 11.055(1B)).

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Relevant Legislation

- Parts 11.260, 201.001 of the Civil Aviation Safety Regulations 1998. - Part 6 of the Civil Aviation Regulations 1988.

Instructions for completion

This form is made up of five (5) parts:

Part

A – Applicant’s Details

B – Submission Checklist

C – Appointment as an Authorised Person under the CAR

D – Appointment as an Authorised Person under the CASR

E – Delegation under the CAR Applicants requesting a re-issue of powers with no changes are only required to complete Part A

Applicants requesting an initial issue in addition to Parts A and B are required to complete Parts C, D, and/or E as appropriate to their application.

Applicants requesting the re-issue of powers with changes or the change to an existing instrument, in addition to Parts A and B are required to complete Parts C, D, and/or E, ONLY for the parts of which there is a regulatory change requested.

An appointment for an airworthiness power is a privilege granted by CASA. Before appointing a delegate or authorised person CASA must be satisfied that there is a need for the appointment of a person to hold a regulatory power.

If at any time you would like assistance with any aspect of this form, please contact CASA on 136 773.

You only need to complete and submit the parts of this application that are relevant to the powers you are requesting.

The completion of this application form is the first step in the application process. On receipt of a completed application form, CASA will send you an estimate of the cost to process your application. You may also be asked for additional information to support the application.

Once you receive your estimate, if you wish to proceed, you will need to pay the estimate and provide any additional information, if requested, to CASA.

CASA may refuse to consider your application if you have not provided all the required information and supporting documents.

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Accuracy of information provided All information you provide will be used to assess if the person nominated meets the requirements and is suitable for the position. An incomplete, poorly prepared or inaccurate application may:

• Result in rejection of the application • Raise doubts about the nominees ability to carry out their functions properly • Result in delays • Add to the cost of the assessment • Result in refusal to approve the appointment

Note: It is an offence to make a false declaration in this form.

Privacy & Your Personal Information

Any information you provide will be treated as confidential. CASA is bound by the Privacy Act 1988 to safeguard personal information within the terms of the Act.

Providing CASA with correct information requested in this application will avoid delays caused by poor or insufficient information.

Submitting your application

Send your application with supporting documentation to:

By post: Permission Application Centre

Permission Issue Section (Brisbane)

GPO Box 2005

CANBERRA ACT 2601

By fax: (07) 3144 7333

By email: regservices@casa.gov.au Applicant’s Details

Your name, address and contact details ensure records contain up to date information about you. Updated information enables CASA to contact you in regard to this application or any future related matter. Please identify whether this application is:

• An "Initial issue" - you are not a current instrument holder; or • A "Re-issue of an expiring instrument with changes" or a " Re-issue of an expiring instrument with no

changes"; or • A "Change to an existing instrument" - you hold a current instrument and would like the scope of an

existing power changed, or you are applying to be appointed for an additional power.

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Applicant’s Declaration

This section must be signed by you as the person named in section A2 of this application It is a condition of the granting of an instrument of delegation that CASA will publish contact details of the instrument holder on the CASA website. In signing this application you agree that CASA may publish your phone/mobile number, facsimile number and email address if you are granted an instrument of delegation/appointment.

Submission Checklist

Please give reason(s) in the space provided, if any of the information required in Part A of this application is; not applicable, was previously provided to CASA or is omitted. CASA will consider your reason(s) and if necessary may request additional supporting information. Note: the absence of any supporting documentation may delay the processing of the application.

Undertaking to Preserve and Safeguard Official Information Signing the Undertaking (Form 1141) permits you to access information, held by CASA, for the purpose of exercising your delegation/appointed powers. The Undertaking can be found at http://www.casa.gov.au/scripts/nc.dll?WCMS:STANDARD::pc=PC_91308. To download this form you should enter the form number (1141) in the field provided.

Identification You need to provide at least two (2) primary identification documents, one of which includes a photograph. If you are unable to provide two (2) primary identification document at least one primary, and two secondary identification documents are to be provided, at least one of which must include a photo. Acceptable forms of identification are:

Primary • Full Birth Certificate • Passport • Citizenship Document (other country) • Australian citizenship certificate • ASIC • AVID.

Secondary • Valid foreign flight crew licence with photo • Valid Australian flight crew licence with photo • Australian drivers licence • Australian Government Employee ID • Australian tertiary student card • Foreign drivers licence card

Statement of Proposed Utilisation In support and justification of the application, submit a statement that describes the proposed utilisation of the requested powers. The statement should include, as applicable, information about the following:

• The expected utilisation of the requested powers and advice of how this has been determined • The proposed region(s) and/or industry sector(s) of activity • Any particular operator(s) for whom the regulatory service(s) will be provided.

This statement is required for applications for new or additional regulatory powers. CASA will use the information in the statement as justification for accepting and assessing the application.

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Qualifications & Experience The criterion document for each power sets out what qualification and experience you are required to meet. You need to provided copies of certificates, evidence of qualifications and a resume of you relevant experience. Written Procedures Manual As part of your application, you are required to submit a written procedures manual. The manual should detail the procedures you will follow when exercising the powers you are requesting. The manual should be structured in a clear and logical manner and contain both general procedures on the process you will use and detailed procedures for each of the powers you have requested. If you are applying for a change to an existing instrument you only need to provide the pages of your procedures manual that are affected by the requested change.

Referee Report

As part of your application you are required to submit a statement from at least one referee who can substantiate all claims made in your application. Where the instrument is conditional upon you being employed by another legal entity (company or individual), a letter of endorsement supporting your application is required from that entity.

If you have any questions regarding this application or require further information, please contact the CASA Permission Application Centre (Brisbane) on 136 773 or by email at regservices@casa.gov.au

Form 1155 Application for Grant, Change or

Re-issue of a Delegation or Appointment

Refer to: CAR 6, CASR 11.260, 201.001

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Part A – Applicant’s Details If you are filling in the form by hand, print neatly with a black or blue ballpoint pen. Some questions contain check boxes. Please mark where appropriate. It is in your interest to ensure that the information you provide is both accurate and complete. This information is used in the calculation of a cost estimate for the assessment of your application. It is an offence under the Commonwealth Criminal Code to make false declaration.

A1 This application is for:

Initial issue Complete Parts A and B Complete Part(s) C, D and/or E as applicable

Re-issue of an expiring instrument with no changes Complete Part A only

Re-issue of an expiring instrument with changes Complete Parts A and B Complete Part(s) C, D and/or E as applicable if requesting additional power(s)/scope Change to an existing instrument

If requesting a reduction in power(s)/scope, provide details:

A2 Personal Details

Surname Given Name(s)

ARN Date of Birth / /

A3 Contact Details

Phone Mobile Fax

Email

Residential Address

Street Suburb

State Postcode Country

Postal Address (Tick if Postal Address is the same as Residential Address )

Street Suburb

State Postcode Country

A4 Have you been charged with or convicted of any offence in Australia, its territories or a foreign country in the last 10 years?

Yes > Enter details below

No

(a) The charges laid and present status:

(Separate sheet attached )

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(b) Was a conviction recorded? Yes > Enter details below

No

(Separate sheet attached )

(c) The penalty imposed:

(Separate sheet attached )

(d) The matters in which a conviction was recorded:

(Separate sheet attached )

A5 Have you been subjected to regulatory action by CASA or the aviation regulator of a foreign country in the last 10 years that has resulted in a fine, conviction, variation, suspension or cancellation of a civil aviation authorisation, licence or certificate?

Yes > Enter details below

No

(a) Was a fine imposed or a conviction / variation recorded? Yes > Enter details below

No

(Separate sheet attached )

(b) The fine imposed:

(Separate sheet attached )

(c) The conviction recorded:

(Separate sheet attached )

(d) Suspension or cancellation ordered:

(Separate sheet attached )

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A6 Applicant’s Declaration

1. I declare that information provided in this application form is true and correct. Giving false or misleading information is an offense under the regulations.

2. I understand the information provided in this application will allow CASA to calculate an estimate of the cost of processing this application

3. I understand and agree that the cost estimate may change, and processing the application may be delayed, if:

• I do not accurately and completely identify my requirement, • the details in this application are subsequently changed, • adequate supporting documentation has not been provided.

4. I understand and agree that for CASA to proceed with this application, I must: • accept the cost estimate • forward the prescribed payment; and • forward all supporting documentation to CASA.

5. I give permission for CASA to send me material relating to this application by email Yes No Note: You are indicating that you are aware of and accept the risk that information sent via

email may be intercepted and read during transmission, not delivered or modified. If you do not accept, material will be sent by post.

6. I understand and agree that if my application is successful, CASA may publish my contact details (mobile phone, fax and email) on the CASA website.

Name Signature Date / /

Note: If your application is for a re-issue of an expiring instrument with no changes this concludes your application.

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Part B – Submission Checklist Please complete this part if you are applying for an initial issue or change to an instrument. Indicate what supporting documentation you are submitting in support of this application.

Undertaking to Preserve & Safeguard Official Information (initial issue only) Attached

Proof of ID (initial issue only) Attached

Statement of Proposed Utilisation (If not, provide reasons below) Attached

Qualification (If not, provide reasons below) Attached

Experience (If not, provide reasons below) Attached

Referee Report (If not, provide reasons below) Attached

Written Procedures Manual (If not, provide reasons below) Attached

Provide the name of the owner of the Procedures Manual:

Provide the title of the Procedures Manual:

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Part C – Appointment as an Authorised Person under the CAR

Please complete this part if you wish to be appointed as an Authorised Person under the Civil Aviation Regulations 1988. Only select any new power(s)/scope being requested.

C1 29A Authority to conduct welding examinations.

Please select one or more weld types below.

Type 1 – Gas Welding Type 2 – Braze Welding Type 3 – Manual Arc Welding

Type 4 – Gas Tung Arc Welding Type 5 – Gas Arc Welding Type 6 – Plasma Arc Welding

C2 42M Authority to approve a system of maintenance.

Please select one or more aircraft types and (if applicable) one or more certification or operational approval subcategories listed below.

Aeroplanes Helicopters Balloons EDTO MSG-3

Reliability Program

RNP

MSG-3

RVSM

Reliability Program Low Visibility

C3 42R Authority to approve changes to a system of maintenance only. Please select one or more aircraft types and (if applicable) one or more certification or operational approval subcategories listed below.

Aeroplanes Helicopters Balloons EDTO MSG-3

Reliability Program

RNP

MSG-3

RVSM

Reliability Program Low Visibility

C4 42ZC(7) Authority to authorise another person to carry out maintenance on a Class A aircraft.

Aeroplanes with more than 38 seats

Entity for whom persons are to be authorised:

C5 262AP(5) Authority to authorise an experimental aircraft to be operated over the built up area of a city or town. The purposes of this power will be the same as the purposes granted under Part D of this form for CASR 21.195A.

C6 262AP(6) Authority to authorise an experimental aircraft to be operated other than by day and under the V.F.R. The purposes of this power will be the same as the purposes granted under Part D of this form for CASR 21.195A.

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Part D – Appointment as an Authorised Person under the CASR Please complete this part if you wish to be appointed as an Authorised Person under the Civil Aviation Safety Regulations 1998. Only select any new power(s)/scope being requested. D1 21.176 Authority to issue standard Certificates of Airworthiness. Please select one or more aircraft types, and (if applicable) one or more certification/operational approval subcategories listed below.

Aeroplanes Helicopters Balloons

Aeroplane with more than 38 seats First of Type aircraft

Other Aircraft (for the purpose of CASR 21.183(4)(a)(ii))

First of Type aircraft

Other Aircraft (for the purpose of CASR 21.183(4)(a)(ii))

First of Type aircraft

D2 21.176 Authority to issue Special Certificates of Airworthiness. Please select one or more certification categories, and (if applicable) one or more aircraft types and certification subcategories listed below.

Restricted Light Sports Aircraft

Aircraft with more than 38 Seats Fixed Wing Aircraft Airship

Gyroplane Glider

Powered Parachute Balloon

Weight Shift Aircraft

Amateur Built Aircraft (ABAA)

D3 21.190 Authority to approve the manufacture of & conduct inspections on ABAA aircraft Aircraft manufactured using one or more of the following materials.

Wood Fabric Composites

Aluminium Alloys Steel

D4 21.195A Authority to issue experimental certificates. Please select one or more purposes, and (if applicable) one or more certification subcategories listed below.

Research & Development Showing Compliance Transport Category Aircraft Transport Category Aircraft

Non Type Certificated Aircraft Non Type Certificated Aircraft Aircraft manufactured under an Australian Production certificate

Aircraft manufactured under an Australian Production certificate

Training Market Survey

Transport Category Aircraft Transport Category Aircraft

Non Type Certificated Aircraft Non Type Certificated Aircraft

Type Certificated Aircraft Type Certificated Aircraft

Exhibition Air Racing

Amateur Built Aircraft Kit Built Aircraft in Primary Category

Prototype Aircraft (for private operations) Light Sport Aircraft

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D5 21.200 Authority to issue a Special Flight Permit (SFP). The standard scope of this power is for the purposes of

- Flying the aircraft to a base where repairs, alterations or maintenance are to be performed or to a point of storage

- Delivering or exporting the aircraft - Evacuating the aircraft from areas of impending danger

For additional purposes select one or more aircraft types and (if applicable) one or more certification or operational approval subcategories listed below.

Aeroplanes Helicopters

Aeroplanes with more than 38 seats To conduct Production Flight Testing

To conduct Production Flight Testing First of Type Aircraft

First of Type Aircraft

Only in conjunction with issuing a C of A Only in conjunction with issuing a C of A 110% of MTOW 110% of MTOW Inside, outside & into & out of Australia

Inside, outside & into & out of Australia To conduct customer demonstration flights

To conduct customer demonstration flights

Balloons

To conduct Production Flight Testing

Inside, outside & into & out of Australia

To conduct customer demonstration flights

D6 21.324 Authority to issue an export airworthiness approval in the form of a Certificate of Airworthiness for an aircraft, or an authorised release certificate for a component.

Please select one or more aircraft types, and (if applicable) one or more certification subcategories listed below.

Aeroplane Helicopter

New Production Aircraft New Production Aircraft

Aeroplane with more than 38 seats

Balloon Class I & II Component

New Production Components

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Part E –Delegation under the CAR Please complete this part if you wish to be delegated CASA powers under the Civil Aviation Regulations 1988. Only select any new power(s)/scope being requested.

E1 37 Delegation to approve either a schedule of permissible unserviceabilities in the form of a minimum equipment list (MEL), or a defect as a permissible unserviceability (PU). Please select MEL and/or PU and (if applicable), one or more certification subcategories listed below.

Minimum Equipment List Permissible Unserviceability

Aircraft with more than 38 seats Aircraft with more than 38 seats

First of Type Aircraft

E2 42ZC(6) Delegation to authorise a person to carry out inspections using non-destructive testing (NDT) methods.