Form - RSVM International/ ASD-B / CPDLC / RNLP / MEL Procedures Manual Order Form ⋆ Black River Aerospace

Please fill in the following information.

If you would like your company's logo to be incorporated into the manuals, please email a high-quality copy of your company logo to management@blackriveraerospace.com.

Please submit all required documents by email to management@blackriveraerospace.com.

The following information is needed to complete your requested application. Please fill out the form as accurately and completely as possible, as this information is critical to the certification process.

Note: Additional information may be needed at a future date.

Note: Except for the information required for our certification project, this is for Black River Aerospace's records. It is not distributed, sold, or shared without your permission.

COMPANY & CONTACT INFORMATION

If a line item does not pertain to your organization, please leave blank or mark with N/A

Will Carry / Not Carry Hazmat

Company Legal Name

Any DBAs Used

PBO Complete Address

Main Contact Information

Main Address (if different than PBO)

Main Operations Base Airport (Name and ID)

FAA Certificate (or Pre-Cert Number)

President / CEO

Dirtector of Operations (DO)

Assistant Director of Maintenance (ADOM)

Chief Pilot (CP)

Assistant Chief Pilot

Agent for Service (AS)

Drug & Alcohol Rep

EFB Adminstrator

Other Information

LAHSO

Yes No

AIRCRAFT INFORMATION

AIRCRAFT MAKE

AIRCRAFT MODEL

TAIL NUMBER

SERIAL NUMBER

AIRCRAFT MAKE

AIRCRAFT MODEL

TAIL NUMBER

SERIAL NUMBER

PROCEDURES MANUAL AND/OR APPLICATION

RVSM ADS-B RNP MMEL (Part 91 only)

International CPDLC/ADS-C MEL Other

OPERATOR INFORMATION

Operator Name (Including DBAs)

Address

City

State

Zip Code

Phone Number

Fax Number

Operator Certificate Number (Part 135 Only)

Phone Number

CFR

Part 91 Part 135 Part 91 & 135

SHIPPING INFORMATION

Same as above

Name

Address

City

State

Zip Code

AIRCRAFT INFORMATION

Special Areas of Operations

Note: If requesting SFAR countries and/or other SAO please contact Black River Aerospace

RVSM modification completed under which method:

Service Bulletin (SB) Supplemental type Certificate (STC) Equipped from factory

Note: We will need a copy of each applicable document.

Date RVSM modification (SV or STC) completed

Date aircraft came from factory (TCDS)

Documents required for RVSM Application:

AFM Supplement that shows the aircraft is qualified for RVSM RVSM STC RVSM Service Bulletins Aircraft Airworthiness and Registration Certificate Documents that show RVSM Maintenance intervals (check maintenance tracking documents) Documents that show 91.411 and 91.413 compliance Any other documents that you feel are relevant

NOTES

RVSM COMPONENTS AND STRUCTURAL AREAS

(Not all aircraft will have all of the components listed below)

Information is listed in a supplemental document

Component(s)

Location(s) & Quantity

Manufacturer & Model

Part Number(s)

Component(s)

Location(s) & Quantity

Manufacturer & Model

Part Number(s)

Component(s)

Location(s) & Quantity

Manufacturer & Model

Part Number(s)

Component(s)

Location(s) & Quantity

Manufacturer & Model

Part Number(s)

Component(s)

Location(s) & Quantity

Manufacturer & Model

Part Number(s)

MAINTENANCE FACILITY MAINTAINING AIRCRAFT (RVSM)

Name of Facility

Repair Station Certificate Number

Contact Person

Address

City

State

Zip Code

Phone Number

Fax Number

FLIGHT CREWMEMBER TRAINING (EXCEPT FOR MEL)

RVSM PILOT TRAINING CERTIFICATES (INCLUDE COPY OF PILOT(S) LICENSE AND MEDICAL) ADS-B PILOT TRAINING CERTIFICATES (INCLUDE COPY OF PILOT(S) LICENSE AND MEDICAL) CPDLC/ADS-B TRAINING CERTIFICATES (INCLUDE COPY OF PILOT(S) LICENSE AND MEDICAL) RNP PILOT TRAINING CERTIFICATES (INCLUDE COPY OF PILOT(S) LICENSE AND MEDICAL)

ADS-B

List Manufacturer's Make, Mode, and Part Number of ADS-B transmitter and Positioning Sources:

Included in Documents

ADS-B Out Only ADS-B In/Out

The following documents are required

AFM ADS-B Content (Must state the ADS-B complies with either 91.227, AC 20-165, or EASA AMC 20-24) Aircraft Maintenance Records (Must verify ADS-B installation per STC or other FAA-approved means) STC (if applicable)

CPDLC (Datalink)/ADS-C

List manufacturer's make, mode, and part number of equipment:

Included in Documents

The following documents are required

AFM Content Aircraft Maintenance Records (Must verify CPDLC/ADS-C installation per STC or other FAA-approved means) Avionics documents showing aircraft airworthiness and datalink eligibility STC (if applicable)

RNP

List manufacturer's Make, Mode, and Part Number of equipment:

Included in Documents

The following documents are required

AFM Content Aircraft Maintenance Records Avionis documents showing aircraft airworthiness and datalink eligibility STC (if applicable)

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