Form 452 - Civil Aviation Safety Authority

Form 452
Payment Advice
Flight Crew Licence Verification
Refer to: CASR 61.700
CASA Stamp:
IMPORTANT INFORMATION FOR APPLICANTS
1: If you do not currently have a CASR Part 61 licence document, you must submit Form
61-9TX. Refer to the form for further information. If CASA does not have a photo of you that is
less than 10 years old, you must also submit Form 61-9PIC.
2: This form can be completed electronically and saved locally to your computer. Once the ARN
has been entered into the first page, it will automatically update in the applicant ARN fields on
subsequent pages. CASA recommends that applicants complete as much of the form electronically
as possible.
3: Please ensure your application and the checklist are completed correctly and that all required
supporting documentation is provided. Incomplete applications will not be accepted and will be
returned to you for amendment. Fields and sections marked with an * are mandatory.
Applicant Details as per Birth Certificate / Passport:
Title:*
______________________________
Family Name:*
______________________________
Given Names:*
______________________________
Date of Birth:*
______________________________
Applicant ARN:*
CONTACT DETAILS
Note: You are required to notify CASA of any changes to your personal contact information (refer to
CASR 11.070). Correspondence, including permissions issued as a result of this application, will be
sent by post to the current postal address according to CASA’s records.
You should notify CASA of any changes using one of the following methods:
• Log onto the CASA Self Service Portal https://portal.casa.gov.au/selfservice/
• Submit Online Change of Details form https://portal.casa.gov.au/casaforms/addrchange.htm
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.
Applicant Checklist*
Enter ‘Y’ or ‘N’ in applicable boxes.
I have completed the Authority to Release Information page (page 2)
I have previously notified CASA of any CAR 5 endorsements to be issued on my CASR Part 61 licence OR
Form 61-9TX is attached
I have previously submitted to CASA a photo in the previous 10 years OR
Form 61-9PIC is attached
I have completed the Payment page (page 3)
Form 452 12/2014
Flight Crew Licence Verification
Page 1 of 3
ARN:
Flight Crew Licence Verification
Flight Crew Licence Verification
Authority to Release Information
I, __________________________, _________________________________, _____ / ____ / ____
First Name
Family Name
Date of Birth
Of (print current residential address)
________________________________, ________________, _________, __________________
Number & Street Name
State
Postcode
Country
Hereby AUTHORISE the Civil Aviation Safety Authority (CASA) to release to:
Nominated Person (s) /
Organisation (s)
Postal Address:
State:
Postcode:
Country:
Telephone:
Email:
Copies of the following documents that are held by CASA:
• My Australia Flight Crew Licence (Including endorsements; ratings and approvals)
• My Aviation Reference Number (ARN)
• My current Aviation Medical Certificate including any conditions attaching to that
Certificate
• Details of any suspensions / cancellation of my Flight Crew Licence and any actions
brought against me by CASA.
Name:
Date: _____ / _____ / _______
Signature:
Form 452 12/2014
Flight Crew Licence Verification
Page 2 of 3
ARN:
Flight Crew Licence Verification
Payment Authorisation
Attach printed receipt and do not complete remainder of this page.
Payment made online
Applicant Details *
Surname:
Given Names:
Mobile:*
Email:*
* These details will be used to follow-up payment issues only. These details will NOT be updated in CASA’s database.
Licence Fees *
Fee Code
Description
Total
Verification Letter (Letter sent to Overseas Authorities confirming validity of Flight Crew
Licence and Medical details. Include a Confirmation report).
24.5
$ 50
Total Cost:
$ ________
Details of Third Party Payment
Individual’s or Organisation’s Full Name:
Email:
Postal Address:
State:
Postcode:
Country:
Contact Phone:
ARN: (if applicable)
Payment Options *
I have enclosed a Cheque or Australian Money Order (please make cheques payable to CASA)
I am paying by credit card – please ensure you complete ALL details below including the card holder
name and the total amount
I hereby authorise the Civil Aviation Safety Authority to debit the following amount from my:
Card Number:
MasterCard
Expiry Date:
Card Holder Name (please print): ………………………………………………………
Signature: ……………………………………………………………………..
Total:
Visa
_____ / _____
$ ____________
Date: ______ / ______ / _______
Submit the Payment Authorisation Form (and Cheque / Money Order / Purchase Order) with the Application Form.
•
Email
[email protected]
•
Mail to:
CASA Licensing and Registration Centre
Paid Stamp
CASA
GPO Box 2005
CANBERRA
•
Fax to:
Form 452 12/2014
ACT 2601
Receipt No:
Initial:
1300 737 187
Flight Crew Licence Verification
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