Demande de licence, qualification, autorisation ou

Transcription

Agence Nationale de l’Aviation Civile du Bénin – Formulaire de demande de licence, de qualification, d’autorisation, de conversion ou validation de licence
FORMULAIRE DE DEMANDE : LICENCE DE PILOTE, INSTRUCTEUR, QUALIFICATION, AUTORISATION,
CONVERSION, VALIDATION
Pilot or Pilot Instructor Licence, Rating, Authorisation, Conversion or Validation Certificate Application
I. Demande de / (Application for):
A.
Délivrance Initiale
Renouvellement
Réémission
Qualification Additionnelle
Autorisation
Validation
Conversion
Original Issuance
Renewal
Reissue
Added Rating
Authorisation
Validation
Conversion
B. Licence / License
Licence de pilote privé
Licence de Pilote professionnel
Licence de Pilote de ligne
Instructeur en vol
Instructeur au sol
Private Pilot Licence
Commercial Pilot Licence
Airline Transport Pilot Licence
Flight Instructor
Ground Instructor
Avion / Aeroplane
Avion / Aeroplane
Avion / Aeroplane
Avion / Aeroplane
Hélicoptère / Helicopter
Hélicoptère /
De Base / Basic
Avancé / Advanced
Instrument
Helicopter
Dirigeable / Airship
Sustentation motorisée
/ Powered - lift
Sustentation
motorisée
Sustentation motorisée
Instrument
/ Powered-lift
/Powered-lift
Ballon / Balloon
Ballon / Balloon
Planeur / Glider
Planeur / Glider
C. Qualifications et Autorisations / Ratings and Authorisations
Qualification de Classe (indiquer la classe) /
Class Rating (indicate class)
Monomoteur (terre) / Single-engine land
Monomoteur (mer) / Single-engine sea
Multi moteur (terre) / Multi-engine land
Multi moteur (mer) Multi-engine sea
Ballon à air chaud / Hot air – balloon
Ballon à Gaz / Gas – balloon
Autre / Other ___________
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Qualification de Type (indiquer le
type) / Type Rating (indicate type)
Qualification de vol aux instruments /
___________________________
Avion / Instrument aeroplane
Hélicoptère / Instrument helicopter
Sustentation Motorisée / Instrument
autorisations / Authorisations
Instrument Rating
powered-lift
Elève Pilote / Student pilot authorisation
Instructeur (simulateur de vol) / Instructor
authorisation for training in a flight simulator
training device
Catégorie II / Category II authorisation
Catégorie III / Category III authorisation
Autre / Other
MPL-01 / ANAC BENIN - 2013
II. Informations sur le Candidat / Applicant Information
1. Nom complet / Legal name (last, first, middle)
2. Numéro Passeport/Carte d’identité / Identification number
3. Date de naissance / Date of birth (dd/mm/yyyy)
(e.g. driver’s licence, passport)
4a. Adresse Permanente / Permanent mailing address (number and
4b. Ville et Etat / Province (City and state/province)
4c. Pays et code Postal / (Country and postal code)
street)
5. Lieu de Naissance (ville, Etat / province,
Pays) / Place of birth (city, state / province, country)
9. Taille / Height (cm)
6. Numéro de téléphone / Telephone number
10. Poids / Weight (kg)
7. Courriel / E-mail address
11. Genre / Gender
8. Nationalité / Nationality
12. Cheveux / Hair
13. Yeux / Eyes
14d. Numéro de la licence / Licence
14e. Date de délivrance / Date issued
number
(dd/mm/yyyy)
Homme / Male
Femme / Female
14a. Détenez-vous présentement
ou avez vous détenu une licence
béninoise ? Si oui, complétez les
blocks 14b au 14e / Do you now hold, or
have you ever held, a Benenese CAA licence?
If yes, complete blocks 14b through 14e.
14b.Si oui, votre licence a t-elle
jamais été suspendue ou
révoquée? / If yes, has your licence ever
14c. Type de licence / Type of licence
been suspended or revoked?
OUI / Yes Date ________
NON / No
OUI / Yes
NON/ No
15a. Comprenez-vous et parlez-vous couramment le Français ? / Do you speak and understand the
15b. Parlez-vous et comprenez-vous l’anglais ? Do you speak and understand the English language?
language of Benenese?
OUI / Yes
NON / No
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OUI / Yes
NON / No
16a. Détenez-vous un certificat médical issu
par un médecin évaluateur agréé par l’ANAC
Bénin ? Si oui, complétez les blocks 16b à
16d / Do you hold a medical certificate issued by the
Benenese CAA? If yes, complete blocks 16b through 16d.
16b. Classe du Certificat médical / Class of
16c. Date de délivrance / Date issued
medical certificate
(dd/mm/yyyy)
16d. Nom du Médecin Aéronautique
Examinateur / Name of aviation medical Examiner
Classe 1 / Class 1
Classe 2 / Class 2
OUI / Yes
NON / No
17a. Dans le cas d’une validation ou
conversion, détenez-vous un certificat
médical émis par votre pays ? Si oui,
indiquez le pays et complétez les blocks 17b
à 17d / For validation or conversion, do you hold a
17b. Classe du certificat médical / Class of
17c. Date de délivrance / Date issued
medical certificate
(dd/mm/yyyy)
17d. Nom de l’Examinateur médical
aéronautique / Name of aviation medical Examiner
Classe 1 / Class 1
Classe 2 / Class 2
medical certificate by your country? If yes, indicate
country and complete blocks 17b through 17d.
OUI Pays / Yes Country _________
Non / No
III. Demande de Licence, de Qualifications, d’Autorisations, de Conversions ou de validation faite sur la base de : / Licence, Rating, Authorisation, Conversion or Validation Certificate Applied for on the Basis
of:
A. Test de Connaissance Théorique /
1. Candidature à un Test de Connaissance de : / Knowledge test applied for
Knowledge Test
2a. Test de connaissance théorique réussi pour : / Knowledge
test successfully completed for
2b. Test de connaisance théorique réussi le : / Knowledge test
date of completion (dd/mm/yyyy)
B. Test Pratique / Skill Test
1. Aéronef à utiliser (si examen en vol
requis) : / Aircraft to be used (if flight test required)
2. Nombre d’heures de vol effectuées dans
ce type avion : / Total time in this aircraft
3. Total des Heures de vol en qualité de
Commandant de bord sur ce type avion : /
Pilot-in-command time in this aircraft
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C. Elève pilote dans un organisme de
formation aéronautique agréé par l’ANAC
(ATO) / Graduate of an Approved Training Organisation
1. Nom de l’Organisme de Formation Aéronautique agréé et adresse (ville,
Etat / Province, Pays) / ATO name and location (city, state/province, country)
2. Numéro d’agrément de l’Organisme de Formation
Aéronautique / ATO certificate number
3. Intitulé de la formation suivie / Course from which graduated
4. Date de fin de formation / Graduation date (dd/mm/yyyy)
(ATO)
D. Détenteur d’une licence étrangère /
1. Pays / Country
2. Type de licence / Type of licence
3. Numéro de la licence / Licence number
2. Date de Qualification / Date rated
3. Echelon ou grade et Numéro de Service /
(dd/mm/yyyy)
Rank or grade and service number
Holder of a Foreign Licence
4. Qualifications / Ratings
E. Compétences Militaire / Military
Competence
1. Service / Service
4. J’atteste avoir effectué au moins 10 heures de vol en qualité de commandant de bord sur les avions militaires de types suivants : / Has
flown at least 10 hours as pilot in command during the past 12 months in the following military aircraft
5. Date du dernier contrôle de compétence en vol (au cours des 12 derniers mois) : / Date of last flight check (past 12 months) (dd/mm/yyyy)
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IV. Enregistrement des Temps de vols (ne pas écrire dans les cellules grisées) / Record of Pilot Time (Do not write in the shaded areas.)
Catégorie Avion /
ESV / Aircraft
Category/FSTD
Avions
Total
Instruction
reçue
Instruction
Received
Solo
Instruction
reçue
vols en
campagne
/ Crosscountry
Instruction
Received
Vols de nuit
pilote aux
commandes /
Night
PIC
Décollages et
atterrissages de
nuit (pilote aux
commandes) /
Night Take-off/
Landing
PIC
PIC
PIC
PIC
CP
Dual
CP
CP
PIC
PIC
PIC
PIC
PIC
CP
CP
Dual
CP
CP
PIC
PIC
PIC
PIC
PIC
CP
CP
Dual
CP
CP
Vols en
campagne
Pilote aux
commandes /
Crosscountry
PIC
Instrument
(PIC/Dual)
PIC
PIC
CP
Commandant
de bord
Pilot in
Command
(PIC)
Vol en
campagne
Solo /
Crosscountry
Solo
Instruction
reçue
vols de nuit
/ Night
Instruction
Received
Décollages et
atterrissages
de nuit /
Night
Take-off /
Landings
Nombre de vols effectués /
Number of Flights/Launches
Aeroplanes
Hélicopteres
Helicopter
Aéronefs à
sustentation
motorisée
Powered lift
Dirigeable
PIC
Airship
Dual
Ballon Balloon
Planeur Gliders
Simulateur de
vol /
Flight Simulation
Training Device
(FSTD)
V. Attestation du Candidat / Applicant’s Certification
Je certifie sur l’honneur que les informations fournies dans ce formulaire sont exactes / I certify that the statements made by me on this application are true.
1. Signature (Nom et Signature) (print name and sign)
2. Date (jj/mm/aaaa) / (dd/mm/yyyy)
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VI. Recommandation en vue du test de connaissances théorique / Endorsement for the Knowledge Test
A. instructeur approuvé par l’ANAC / Authorised Instructor
J’ai personnellement instruit le candidat dans les sujets requis par les RABs pour la licence, l’autorisation ou le certificat et je considère que ce candidat est prêt à passer le test de
connaissance théorique. (I have personally instructed the applicant in the subject areas required by the RAB for the licence, rating, authorisation, or certificate and consider this person ready to take the knowledge test).
1. Date (jj/mm/aaaa) Date (dd/mm/yyyy)
2. Nom de l’instructeur et signature
3. Numéro de Licence de l’instructeur /
4. Date d’expiration de la licence de
Instructor’s name and signature (print name and sign)
Instructor’s licence number
l’instructeur (jj/mm/aaaa) / Instructor’s licence
expiration date (dd/mm/yyyy)
B. Organisme de Formation agréé / Approved Training Organisation
Le candidat à achevé avec succès notre cours intitulé ________________________________ et est recommandé au test de connaissance théorique _________________________________
(The applicant has successfully completed our ____ approved course, and is endorsed for the _____ test).
1. Date (jj/mm/aaaa) (dd/mm/yyyy)
2. Nom de l’OFA / ATO name
3. Numéro d’agrément de l’OFA / ATO
certificate number
4. Nom, Titre et Signature du directeur de
l’OFA. Name, title and signature of ATO official (print
name, title and sign)
C. Autorisation de l’ANAC / CAA Authorisation
1.
J’ai personnellement revu la demande du candidat, son identité et autres documents exigés dans le cadre de la présente demande et j’atteste que cette demande est conforme aux
exigences du RAB 01 et ses procédures associées relatives à la licence, qualification, autorisation ou certificat demandé et l’autorise à passer le test de connaissance théorique demandé. I
have reviewed this person’s application, identification and other required documentation and find this applicant meets the requirements of the RAB for the licence, rating, authorisation or certificate sought and authorise the applicant to
take the knowledge test.
Test de connaissance initial / Initial knowledge test
Reprise de test de connaissance / Re-take of passing test
Reprise de test après échec / Re-test after failure
2.
J’ai personnellement revu la demande du candidat, son identité et autres documents exigés dans le cadre de la présente demande et j’atteste que cette demande n’est pas
conforme aux exigences du RAB 01 et ses procédures associées relatives à la licence, qualification, autorisation ou certificat demandé et ne l’autorise pas à passer le test de connaissance
théorique demandé. I have reviewed this person’s application, identification and other required documentation and find this applicant does not meet the requirements of the RAB for the licence, rating, authorisation or certificate
sought and is not authorised to take the knowledge test.
3. Remarques (si applicable) Remarks (if any)
___________________________________________________________________________________________________________________________________________________________
4. Nom, Titre et signature de l’inspecteur ANAC qui a effectué la revue de la présente demande / Name, title and signature of the CAA official who conducted the review
Nom et Titre (printed name and title) _______________________________________________________
(signature)_____________________________________________________________
Date (jj/mm/aaaa) (dd/mm/yyyy) ____/______/_____.
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VII. Recommandation en vue du test pratique / Endorsement for the Skill Test
A. instructeur approuvé par l’ANAC / Authorised Instructor
J’ai personnellement instruit le candidat dans les sujets requis par les RABs pour la licence, l’autorisation ou le certificat et je considère que ce candidat est prêt à passer le test pratique. (I
have personally instructed the applicant in the subject areas required by the RAB for the licence, rating, authorisation, or certificate and consider this person ready to take the knowledge test).
1. Date (jj/mm/aaaa) Date (dd/mm/yyyy)
2. Nom de l’instructeur et signature
3. Numéro de Licence de l’instructeur /
Instructor’s name and signature (print name and sign)
Instructor’s licence number
4. Date d’expiration de la licence de
l’instructeur (jj/mm/aaaa) / Instructor’s licence
expiration date (dd/mm/yyyy)
B. Organisme de Formation agréé / Approved Training Organisation
Le candidat à achevé avec succès notre cours intitulé _______________________________________________ et est recommandé au test pratique _________________________________
(The applicant has successfully completed our ____ approved course, and is endorsed for the _____ test).
1. Date (jj/mm/aaaa) (dd/mm/yyyy)
2. Nom de l’OFA / ATO name
3. Numéro d’agrément de l’OFA / ATO
certificate number
4. Nom, Titre et Signature du directeur de
l’OFA. Name, title and signature of ATO official (print
name, title and sign)
C. Autorisation de l’ANAC / CAA Authorisation
1.
J’ai personnellement revu la demande du candidat, son identité et autres documents exigés dans le cadre de la présente demande et j’atteste que cette demande est conforme aux
exigences du RAB 01 et ses procédures associées relatives à la licence, qualification, autorisation ou certificat demandé et l’autorise à passer le test pratique demandé. I have reviewed this
person’s application, identification and other required documentation and find this applicant meets the requirements of the RAB for the licence, rating, authorisation or certificate sought and authorise the applicant to take the skill test.
Test pratique initial / Initial skill test
Reprise de test après échec / Re-test after failure
Renouvellement / Renewal
Réémission / Re-issue
2.
J’ai personnellement revu la demande du candidat, son identité et autres documents exigés dans le cadre de la présente demande et j’atteste que cette demande n’est pas
conforme aux exigences du RAB 01 et ses procédures associées relatives à la licence, qualification, autorisation ou certificat demandé et ne l’autorise pas à passer le test pratique
demandé. I have reviewed this person’s application, identification and other required documentation and find this applicant does not meet the requirements of the RAB for the licence, rating, authorisation or certificate sought and is not
authorised to take the skill test.
3. Remarques (si applicable) Remarks (if any)
___________________________________________________________________________________________________________________________________________________________
4. Nom, Titre et signature de l’inspecteur ANAC qui a effectué la revue de la présente demande / Name, title and signature of the CAA official who conducted the review
Nom et Titre (printed name and title) _______________________________________________________
(signature)_____________________________________________________________
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VIII. Réservé / Reserved
IX. Compte-rendu de test pratique (Examinateur ou Inspecteur ANAC) / Skill Test Report (Examiner or CAA Inspector)
1. Attestation de l’Examinateur ou de l’Inspecteur / Examiner or inspector statement
a.
J’ai personnellement revu le carnet de vol et/ou le dossier de formation du candidat et j’atteste qu’il (elle) répond aux exigences pertinentes du RAB 01 et procédures
associées pour la licence, la qualification, l’autorisation ou le certificat demandé. / I have personally reviewed this applicant’s pilot logbook and/or training record, and certify that the individual meets the
pertinent requirements of the RAB for the licence, rating, authorisation or certificate sought.
b.
J’ai personnellement testé / contrôlé en vol ce candidat, conformément aux procédures et exigences pertinentes en vigueur avec les résultats ci-après / I have personally
tested/checked this applicant in accordance with pertinent procedures and requirements with the results indicated below.
Admis / Approved
Echec – lettre de refus établie (Original joint) / Disapproved – notice of denial issued (original attached)
c.
J’ai personnellement évalué ce candidat, et atteste qu’il répond aux exigences de compétences linguistiques pour : / I have personally checked that this applicant meets the language
proficiency requirements for the:
Français / French
Anglais / English language
2. Lieu du Test (Centre, ville, Etat ou province, Pays) Location
3. Durée du test / Duration of test
4. Détails du Temps alloué au test / Test duration breakdown
of test (facility, city, state or province, country)
Ground hours __________
FSTD hours __________
Flight hours __________
5. Licence, Qualification, autorisation ou certificat objet du
test / Licence, rating, authorisation or certificate for which tested
8. Date (jj/mm/aaaa) / (dd/mm/yyyy)
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6. Type (s) d’aéronef utilisé / Type(s) of aircraft used
7. Immatriculation de l’aéronef / Registration number(s)
9. Nom de l’Examinateur ou de l’inspecteur
et signature / Examiner’s or inspector’s name and
10. Numéro d’examinateur désigné ou
numéro de la licence de l’inspecteur /
11. Date d’expiration de la désignation de
l’examinateur / Examiner’s designation expiration
signature (print name and sign)
Examiner’s designation number or inspector’s licence
number
date (dd/mm/yyyy)
X. Rapport de l’ANAC / CAA Report
A. Décision de l’ANAC / CAA Action
B. Pièces Jointes / Attachments
Délivrer la Carte de Stagiaire / Issue student pilot authorisation
Recommandation de l’Examinateur ou inspecteur / Examiner/Inspector recommendation
Admis / Accepted
Rejeté (Echec) / Rejected
Délivrance de la licence / Issue of licence
Renouvellement de la licence / Renewal of licence
Réémission de la licence / Re-issue of licence
Délivrance de la Qualification / Issue of rating
Renouvellement de la Qualification / Renewal of rating
Réémission de Qualification / Re-issue of rating
Délivrance de l’autorisation / Issue of authorisation
Renouvellement de l’autorisation / Renewal of authorisation
Réémission de l’autorisation / Re-issue of authorisation
Délivrance du certificat de validation / Issue of validation certificate
Autorisation d’Elève Pilote (copie) / Student pilot authorisation (copy)
Licence expirée / Superseded licence
Rapport de Test de connaissance théorique / Knowledge test report
Rapport de test pratique / Skill test report
Lettre de rejet (refus) / Notice of denial
Lettre d’interruption / Letter of discontinuance
Certificat – Diplôme (copie) / Graduation certificate (copy)
Copie du certificat médical étranger / Copy of foreign medical certificate
Copie de la carte d’identité ou du passeport / Copy of applicant’s identification
Vérification de l’authenticité de la licence étrangère / Verification of authenticity of foreign licence
Autre / Other _________________________
C. Identification du candidat / Applicant’s Identification
Type d’identification officielle fournie / Type of government-issued identification __________________________________________________________________________
Numéro du document d’identification / Identification number _______________________________________________
Date d’expiration / Expiration date ____________________
D. Autorisation de l’ANAC / CAA Authorisation
1.
la documentation exigée comme pièce jointe est présente et la licence, qualification, autorisation ou certificat recherché peut être émis / Application documentation is in order and the
licence, rating, authorisation or certificate may be issued.
___________________________________________________________________________________________________
des documents exigés sont manquants et la demande est retournée au candidat / Application is missing the following documentation and will be returned to the applicant.
Documents Manquants / Missing documentation ____________________________________________________________________________________________________
2.
Nom, Titre et signature de l’inspecteur ANAC qui a effectué la revue / Name, title and signature of the CAA official who conducted the review
Nom et Titre (printed name and title) __________________________________________________ (signature)_____________________________________________________________
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XI. Délivrance ANAC / CAA Issuance
A. Licence, Qualification, autorisation ou certificat délivré / Licence, Rating, Authorisation or Validation Certificate Issued
Licence __________________________________________________________________________________________ Expiration date* __________________
Qualification / Rating(s) _______________________________________________________________________________ Expiration date* __________________
Autorisation / Authorisation _____________________________________________________________________________ Expiration date* __________________
Certificat de validation / Validation certificate _________________________________________________________________ Expiration date* __________________
* Date format (jj/mm/aaaa) / (dd/mm/yyyy)
B. Autorisation de l’ANAC / CAA Authorisation
Nom, Titre et signature de l’officiel ayant formalisé la délivrance / Name, title and signature of CAA official who completed the issuance
___________________________________________________________________________________________
(printed name and title)
___________________________________________________________________________________________
(signature)
Date (jj/mm/aaaa) (dd/mm/yyyy)
_________________________
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INSTRUCTIONS POUR REMPLIR LE FORMULAIRE / INSTRUCTIONS FOR COMPLETION OF FORM MP-L01
I. Application for:
Block 4a. Permanent mailing address (number and street).Enter the residence number and
Complete appropriate block(s)
street name of your permanent address.
Block A.The applicant must check the appropriate box.
CAA policy requires that you use your permanent mailing address. Justification must be
 Original Issuance – First (direct) issuance of a type of licence (e.g. private pilot).
provided on a separate sheet of paper signed and submitted ith the application hen a PO
 eneal – eneal of the licence ithin the validity period of the licence.
Box or rural route number is used in place of your permanent physical address. A map or
 eissue – eissue of the licence after the licence validity period has expired.
directions must be provided if a physical address is unavailable.
 Added ating – Adding a rating to an existing licence.
Block 4b. City and state or province. Enter the city of your permanent address and the state
 Authorisation – Either stand-alone authorisation (e.g.student pilot) or added to a licence
or province as applicable.
(e.g. Category II authorisation).
Block 4c. Country and postal code. Enter the country and postal code of your permanent
 alidation – equest for a validation certificate to be issued on the basis of a foreign
address.
licence. Check the box and proceed toSection II, Applicant Information.
Block 5. Place of birth. Enter the city of birth and the state or province as applicable. Enter the
 Conversion – equest to convert a licence based on a foreign licence. Check the box and
country here you ere born.
proceed to Section II, Applicant Information.
Block 6. Telephone number. Enter your telephone number.
Block B. Licence. The applicant for the direct issuance of a type of licence must check the
Block 7. E-mail address. Enter your E-mail address. If you do not have an E-mail address, enter
appropriate box for the licence and aircraft category rating being sought.
“None” or “N/A”.
Block C. atings and Authorisations. The applicant for the direct issuance of a rating or
Block 8. Nationality. Indicate your nationality from your passport. If you have more than one
authorisation must check the appropriate box for the rating or authorisation being sought.
nationality, indicate so.
II. Applicant Information
Block 9. Height.Enter your height in centimetres. Do not enter fractions. Use hole
centimetres only.
Block 1. Legal name. Enter your legal name. Do not change the name on subsequent
Block 10. Weight. Enter your eight in kilograms. Do not enter fractions. Use hole kilograms
applications unless it is officially indicated to the authority that the name is changed
only.
accompanied by a copy of the marriage licence, court order or other document verifying the
Block 11. Gender.Check male or female.
name change.
Block 12. Hair. Enter the colour of your hair. If bald, enter “bald”. Colour should be listed as
Block 2. Identification number.Enter the identification number from the driver’s licence,
black, red, bron, blonde or gray.
passport or other government issued identification (as specified by the CAA).
Block 13. Eyes. Enter the colour of your eyes. The colour should be listed as blue, bron,
Block 3. Date of birth.Enter the date of birth as eight digits (dd/mm/yyyy). Use numeric
black, hazel, green or gray.
characters, for example, 20/10/1983, instead of 20 October1983. Check to see that the date
Block 14a. Do you no hold, or have you ever held, a Benenese CAA licence?Check yes or no.
of birth is the sameas it is on the medical certificate.
If yes, complete blocks 14b through 14e, otherise proceed to block 15a.
Block 14b. If yes, has your licence ever been suspended or revoked?Check yes or no and, if
yes, indicate the date.
Block 14c. Type of licence. Enter the type of pilot licence you hold or have held (PPL, CPL,
ATPL).
Block 14d. Licence number. Enter the licence number as it appears on your pilot licence.
Block 14e. Date issued. Enter the date your pilot licence as issued.
Block 15a. Do you speak and understand the language of Benenese (national language)?
Check yes or no.
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Block 15b. Do you speak and understand the English language? Check yes or no.
Block 16a. Do you hold a medical certificate issued by the Benenese CAA? Check yes or no. If
yes, complete blocks 16b through 16d, otherise proceed to block 17a.
Block 16b. Class of medical certificate. Check Class 1 or Class 2 as applicable.
Block 16c. Date issued. Enter the date the Benenese medical certificate as issued as eight
digits (dd/mm/yyyy).
Use numeric characters, for example, 20/10/1983, instead of 20 October 1983.
Block 16d. Name of aviation medical examiner. Enter the name of the Benenese aviation
medical examiner as shon on the Benenese medical certificate.
Block 17a. For validation or conversion, do you hold a medical certificate by your country?
Check yes or no. If yes, enter the name of your country and complete blocks 17b through 17d,
otherise proceed to section III.
Block 17b. Class of medical certificate. Check Class 1 or Class 2 as applicable.
Block 17c. Date issued. Enter the date the medical certificate as issued as eight digits
(dd/mm/yyyy). Use numeric characters, for example, 20/10/1983, instead of 20 October
1983.
Block 17d. Name of aviation medical examiner. Enter the name of the aviation medical
examiner as shon on the medical certificate.
III. Licence, Rating, Authorisation, Conversion or Validation Certificate Applied for on the
Basis of:
Block A. Knoledge test
1. Knoledge test applied for. Indicate hich knoledge test the applicant is applying to take
(if applicable).
2a. Knoledge test successfully completed for. Enter the type of knoledge test the applicant
has completed (if applicable).
2b. Knoledge test date of completion. Enter the date the knoledge test as completed as
eight digits (dd/mm/yyyy). Use numeric characters, for example, 20/10/1983, instead of 20
October 1983.
Block B. Skill test
1. Aircraft to be used. If a flight test is required, enter the make and model of each aircraft to
be used. If a flight simulation training device is to be used, please indicate.
2. Total time in this aircraft. Enter your total flight time in each make and model aircraft to be
used.
3. Pilot-in-command time in this aircraft. Enter your pilot-in-command time in each make and
model aircraft to be used.
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Block C. Graduate of an Approved Training Organisation (ATO)
1. ATO name and location. Enter the name and location of the approved training organisation
(ATO) as shon on the graduation certificate. Be sure to include the city, state or province as
applicable, and country.
2. ATO certificate number. Enter the ATO certificate number as shon on the graduation
certificate.
3. Course from hich graduated. Enter the name of the course from hich you graduated as
shon on the graduation certificate.
4. Graduation date. Enter the date of graduation from the course indicated as eight digits
(dd/mm/yyyy). Use numeric characters, for example, 20/10/1983, instead of 20 October
1983.
Block D. Holder of a Foreign Licence
1. Country. Enter the country hich issued the licence.
2. Type of licence. Enter the type of licence issued (e.g. private, commercial, etc.).
3. Licence number.Enter the licence number as it appears on your licence.
4. atings. Enter all ratings that appear on the licence.
Block E. Military Competence
1. Service.Enter your branch of service.
2. Date rated. Enter the date you ere rated as a military pilot (date qualified to fly as pilot in
command) as eight digits (dd/mm/yyyy). Use numeric characters, for example, 20/10/1983,
instead of 20 October 1983.
3. ank or grade and service number. Enter your rank or grade and service number.
4. Flight hours. Enter at least 10 hours flon as a pilot in command in the last 12 months and
the type of military aircraft flon.
5. Date of the last flight check (past 12 months). Enter the date of your last flight check as
October 1983.
IV. Record of Pilot Time
Enter the information as required. Only fill in the blocks that apply. The minimum pilot
experience required by the appropriate regulation must be entered. It is recommended,
hoever, that all pilot time be entered. If decimal points are used, be sure they are legible.
Night flying must be entered hen required. Flight simulator training device time may be
entered in the appropriate boxes.
V. Applicant’s Certification Complete appropriate block(s)
Block 1. Signature. Print and sign your name.
Block 2. Date. Enter the date you sign the application as eight digits (dd/mm/yyyy). Use
numeric characters, for example, 20/10/1983, instead of 20 October 1983.
VI. Endorsement for the Knowledge Test
Block A. Authorised Instructor
1. Date. Enter the date you sign the application as eight digits (dd/mm/yyyy). Use numeric
characters, for example, 20/10/1983, instead of 20 October 1983.
2. Instructor’s name and signature. Authorised instructor should print and sign name.
3. Instructor’s licence number. Enter the instructor’s licence number.
4. Instructor’s licence expiration date. Enter the expiration date of the instructor licence as
October 1983.
Block B. Approved Training Organisation (ATO)
Enter the name of the approved course the applicant completed and indicate the test the
ATO is endorsing the applicant to take.
1. Date. Enter the date an ATO official signs the application as eight digits (dd/mm/yyyy). Use
2. ATO name. Enter the name of the ATO as shon on the graduation certificate.
certificate.
4. Name, title and signature of ATO official. Print the name and ATO position title, and sign.
Page 13 sur 14
Block C. CAA Authorisation
1.Check the box if the applicantmeets the requirements to take the applicable knoledge
test.
Check the appropriate box to indicate if this is the applicant’s initial knoledge test, a re-take
of a passing test or a re-test after failure of a knoledge test.
2.Check the box if the applicant does not meet the requirements to take the applicable
knoledge test.
3.Enter remarks, as needed.
4. Print the name and title of the CAA official ho conducted the revie. Sign and date the
application. Enter the date as eight digits (dd/mm/yyyy). Use numeric
VII. Endorsement for the Skill Test
Block A. Authorised Instructor
1. Date. Enter the date you sign the application as eight digits (dd/mm/yyyy). Use numeric
2. Instructor’s name and signature. Authorised instructor should print and sign name.
3. Instructor’s licence number. Enter the instructor’s licence number.
4. Instructor’s licence expiration date. Enter the expiration date of the instructor licence as
October 1983.
Block B. Approved Training Organisation (ATO)
Enter the name of the approved course the applicant completed and indicate the test the
ATO is endorsing the applicant to take.
1. Date. Enter the date an ATO official signs the application as eight digits (dd/mm/yyyy). Use
2. ATO name. Enter the name of the ATO as shon on the graduation certificate.
certificate.
4. Name, title and signature of ATO official. Print the name and ATO position title, and sign.
Block C. CAA Authorisation.
1.Check the box if the applicantmeets the requirements to take the applicable skill test. Check
the appropriate box to indicate if this is the applicant’s initial skill test, a re-test after failure of
a skill test, a reneal or re-issue.
2.Check the box if the applicant does not meet the requirements to take the applicable
knoledge test.
3.Enter remarks, as needed.
4.Print the name and title of the CAA official ho conducted the revie. Sign and date the
application. Enter the date as eight digits (dd/mm/yyyy). Use numeric characters, for
example, 20/10/1983, instead of 20 October 1983.
VIII. Reserved
IX. Skill Test Report (Examiner or CAA Inspector)
Block 1. Examiner or inspector statement. Items a, b, and c must be addressed.
a.The examiner/inspector must check the box to indicate that he/she personally revieed the
applicant’s documents and the applicant meets the pertinent requirements of the ABs.
b.The examiner/inspector must check the box to indicate that he/she personally tested the
applicant in accordance ith the pertinent procedures and requirements. Indicate if the
applicant is approved or disapproved by checking the appropriate box.
c.The examiner/inspector mustcheck the box that he/she personally checked the applicant’s
language proficiency for both the language of Benenese and the English language.
Block 2. Location of test (facility, city, state or province, country). Enter the test facility name
and location.
Block 3. Duration of test. Enter the duration of the test.
Block 4. Test duration breakdon. Enter the number of hours spent during the test on the
ground (oral), in a flight simulation training device and/or in flight.
Block 5. Licence, rating, authorisation or certificate for hich tested. Enter the licence, rating,
authorisation or certificate for hich tested.
Block 6. Type(s) of aircraft used. Enter the type(s) of aircraft used during the test.
Block 7. egistration number(s). Enter the registration number(s) of the aircraft used during
the test.
Block 8. Date. Enter the test date as eight digits (dd/mm/yyyy). Use numeric characters, for
Block 9. Examiner’s or inspector’s name and signature. Print and sign your name.
Page 14 sur 14
Block 10. Examiner’s designation number or inspector’s licence number. Enter the examiner’s
designation number or the inspector’s licence number.
Block 11. Examiner’s designation expiration date. Enter the examiner’s designation expiration
date as eight digits (dd/mm/yyyy). Use numeric characters, for example, 20/10/1983, instead
of 20 October 1983.
X. CAA Report
Block A. CAA Action. Check the appropriate box.
Block B. Attachments. Check to indicate that applicable documentation is attached.
Block C. Applicant’s Identification. Enter the type of government-issued identification, the
identification number, and the expiration date.
Block D. CAA Authorisation. Check the appropriate box to indicate if the applicant meets the
licensing requirements or if the application is incomplete and ill be returned to the
applicant. Print the name and title of the CAA official ho conducted the revie and sign the
application. Enter the date of the revie as eight digits (dd/mm/yyyy). Use numeric
XI. CAA Issuance
Block A. Licence, ating, Authorisation or alidation Certificate Issued. Check the appropriate
box and indicate the grade of licence, rating(s), authorisation or validation certificate
received. Enter the expiration date as eight digits (dd/mm/yyyy). Use numeric characters, for
Block B. CAA Authorisation. Print the name and title of the CAA official ho completed the
issuance and sign the application. Enter the date of the issuance as eight digits (dd/mm/yyyy).
Use numeric characters, for example, 20/10/1983, instead of 20 October 1983.

Demande de licence, qualification, autorisation ou

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