MINISTRY OF TRANSPORTATION

DIRECTORATE GENERAL OF CIVIL AVIATION

Office Complex Soekarno-Hatta International Airport, C3 St., Tangerang, Banten- Indonesia
Telp.: (+6221) 225 66288, (+6221) 256 08887 Fax. : (+6221) 225 66399
Website : hubud.dephub.go.id; e-mail: daao_dgca@dephub.go.id

UAS OPERATOR CERTIFICATE APPLICATION

Section 1: Personal Details

Family Name Nusbih Given Name Muhammad Zalkeyfal Other Names -

Gender Title: Mr Date of Birth 09-06-2004

Male ✔ Female

Nationality Indonesia

Section 2: Address Details

Residential Address
(Must be your current place of
residence, PO Box not accepted)
Postal Address
(If different to Physical Address)
Estate PT.Mahakam Persada Sakti,Desa Beno Harapan,Kecamatan Batu Ampar
State: Kalimantan Timur Country: Indonesia
Postcode:90241
Bumi Permata Sudiang Blok E1 No 11,Kecamatan Biringkanaya,Kelurahan Sudiang, Kota Makassar
State: Sulawesi Selatan Country: Indonesia
Postcode: 90241

Section 3: Contact Details

Phone 089524412832 Mobile 089524412832 Fax -
Email keyfal123@gmail.com
Section 4: Proof of Identity
Type of ID attached Indonesian Passport (if applicable) Indonesian ID Card

Number: Number: 7371110906030006

Section 5: Detail of the Applicant

5.1 Please indicate which applies to you:
✔ I am applying for an initial issue of a UAS Operator Certificate
I am applying for a variation to an existing UAS Operator Certificate
Existing UAS Opeartor Certificate No

5.2 Enter details of Trading Name

Name (1) Registration Number *)

Name (2) Registration Number *)

*) Filled by DGCA Officer
If there are more than two names, please attach a separate sheet containing the same details as above.

Section 6: Detail of Proposed Operations

UAS Operations UAS Details
Gross Weight/
Type of Operation*) UAS Training**) Category ***) Manufacturer Type
Capacity
: Other Theory & Practice Quadcopter DJI Technology co

DGCA Form No. 107-01 (Jan 2018) Page 1 of 2

*) Type of Operation: Aerial Work, Aerial photography, Aerial Spotting, Aerial Surveying, and or other specify
**) Theory only or theory and practice
***) Airplane, rotary, quad copter, or other specify

Section 6: Applicant Declaration

1. I declare that the information provided in this application form is true and correct.
Giving false or misleading information is an offence under the regulations
2. I understand that the information provided in this application will allow DGCA to calculate an
estimate for service for processing this application.

3. I understand and agree that the cost estimate may change, and processing the application may be
delayed if:
• The application does not accurately and completely identify my requirements; or
• The details in this application are subsequently changed; or
• Adequate supporting documentation has not been provided.

4. I understand and agree that for DGCA to proceed with this application, I / We must:
• Accept the cost estimate; and
• Forward the prescribed payment; and
• Forward all supporting documentation to the Permissions Issue Team.
5. I give permission for DGCA to send material relating to this application by email.
✔ Yes No
Note: I am 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).

Name Muhammad Zalkeyfal Nusbih

Signature Date 12-04-2023

Section 7: Submission Checklist

1. DGCA Form No. 47-11 for each UA ✔
2. Insurance
3. Copy of UAS Training Certificate and Syllabus ✔
4. Operations Manual ✔
5. List any additional documentation you have provided:
a.
b.
c.

DGCA Form No. 107-01 (Jan 2018) Page 2 of 2