Form 725

Application for Issue of a Special Flight Permit Refer to: AC 21-9

Form 725 01/2019 Application for Issue of a Special Flight Permit Page 1 of 3

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 Space 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.

1. Aircraft Identification (As noted on the aircraft data plate and the certificate of registration)

Registration Mark Manufacturer and Manufacturer’s Designation (Model) of Aircraft

Aircraft Serial Number

Place of Manufacture Year of Manufacture

2. Details of Applicant

Name of Applicant/Applicant’s Agent ARN

Postal Address

State Postcode Country

Telephone Facsimile

Email

3. Purpose for Special Flight PermitFerry for Repairs, Maintenance, Storage etc. Delivery or Export

Production Flight Test Evacuating Aircraft

Customer Demonstration Flight (new a/c) Search and Rescue

State of Emergency In Excess of MTOW

Note: See section 5 for other details required from applicant for the issue of the permit.

4. Proposed Itinerary for Purpose

To: (place)

Flight Details

From: (place)

Period For Which Special Flight Permit Requested From: To: Proposed Departure Date:

5. Other Details Required for the Issue of the Permit(a) Crew required to operate aircraft and its equipment (eg pilot, co-pilot, navigator etc) see subregulation 21.199(1)(c)

Application for Issue of a Special Flight Permit Registration Mark

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(b) Ways, if any, in which aircraft does not comply with applicable airworthiness standards. (eg. major defects, damage,unapproved modifications, outstanding Airworthiness Directives (ADs), etc) see subregulation 21.199(1)(d)

i. Is the aircraft fitted with a ferry tank? No Yes (Copy of approval attached)

ii. Has any change affected aircraft weight and balance? No Yes (Copy of W&B attached)

(c) Restrictions considered necessary by applicant for safe operation of aircraft. see subregulation 21.199(1)(e)

Hangered

Yes No Copy of MR attached

(d) Other information (aircraft condition) see subregulation 21.199(1)(f)

i. If the aircraft has been stored has it been stored? in the open

ii. For aircraft maintained under CAR 1988, has the Maintenance Release expired?

a) If “Yes”, for how long? hours Date:

b) For what reason did the Maintenance Release expire?

iii. For aircraft maintained under CASR Part 42, what reason(s) prevent a CRS being issued?

iv. When was the aircraft last flown? Date:

v. When was the last time fresh fuel was added? Date:

vi. Is there any outstanding MELs or PUs? No

vii. When was the engine last run? Date:

viii. Has the engine(s) been maintained to manufacturer’s procedures for inactive engine protection?

Yes Attach evidence of maintenance

No Attach details of alternative procedures

If evidence of inactive engine protection maintenance is not submitted with the application then the engine/s should be treated as if not protected

ix. Is there damage to the aircraft?

Yes (photographs and/or Engineering assessment attached)

No

Note:

Yes Details attached

Application for Issue of a Special Flight Permit Registration Mark

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6. Applicant’s Declaration

I certify that this application is being made by the registered operator OR

I certify that this application is being made by an agent appointed by the registered operator, as I have been appointed by

the registered operator, to act on his/her behalf with respect to

this application.

Name: Signature: Date:

Note: Please submit this form to your local regional office – see www.casa.gov.au/contact for details or an authorised person for further action.

7. CASA Delegate/Authorised Person

I am satisfied that the aircraft described above can be reasonably expected to be capable of safe flight, for the intended purpose, for the issue of a Special Flight Permit to carry out the flight/ flights described above.

Conditions apply Special Flight Permit Number:

Issue Date: Expiry Date:

CASA Delegate Authorised Person:

Name: Signature: Date:

Instrument of Appointment No: ARN: _______________________ Send, within 7 Days, the documents to the Civil Aircraft Register via facsimile 02 6217 1991 or aircraftregistration@casa.gov.au or “Civil Aircraft Register” GPO Box 2005 Canberra ACT 2601.