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542 Application for Airman Personal License (Other than Flight Crew Members)
CAAP application form for airman personal licence
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APPLICATION FOR
AIRMAN PERSONAL LICENSE
[OTHER THAN FLIGHT CREWMEMBERS]
A. APPLICATION IS HEREBY MADE FOR
LICENSE:
ISSUANCE
INSTRUCTIONS
Print or type. Submit original only to the Flight Standards
Inspectorate Service or a CAAP Authorized Person. If
additional space is required, use an attachment
REISSUANCE/REINSTATEMENT
RENEWAL
1
FLIGHT DISPATCHER
5
AVIATION MAINTENANCE SPECIALIST
9
2
GROUND INSTRUCTOR
6
AERONAUTICAL STATION OPERATOR
10
3
AVIATION MAINTENANCE TECHNICIAN
7
AIR TRAFFIC CONTROLLER
4
INSPECTION AUTHORIZATION
8
ADDITIONAL OF THE FOLLOWING PEL
AIR TRAFFIC SAFETY ELECTRONIC PERSONNEL
REMOTELY PILOTED AIRCRAFT
OTHERS: ______________________________
B. THE FOLLOWING RATING IS INVOLVED:
1
..(SPECIFY CLASS)
5
ELECTRONICS
SPECIALIZED....
TYPE RATING....
….......(SPECIFY)
AIRFRAME
3
4
POWERPLANT
2
C. AIRMAN PERSONAL INFORMATION:
1. NAME (Last, First, Middle)
2. PERMANENT ADDRESS (House Number, Street and Brgy)
3. TELEPHONE AND FAX
4. CITY
5. DATE OF BIRTH
6. AGE
7. PLACE OF BIRTH
12. HAIR
13. EYES
PROVINCE
ZIP CODE
8. NATIONALITY (CITIZENSHIP)
COUNTRY
9. LANGUAGE (Proficiency Level)
(DAY, MONTH, YEAR)
10. HEIGHT
11. WEIGHT
cms
14. SEX
15. E-MAIL ADDRESS
16. PEL No.
kgs
D. CURRENT AIRMAN LICENSE INFORMATION
1. LICENSE NUMBER
2. LICENSE TYPE
3. STATE OF ISSUE
4. DATE ISSUED
5. RATINGS:
6. LIMITATIONS:
7. ENDORSEMENTS:
E. LICENSE OR RATING APPLIED FOR ON BASIS OF COMPLETION OF:
F. MEDICAL EVALUATION INFORMATION:
1. CLASS OF CERTIFICATE
2. STATE OF ISSUE
1.
EXPERIENCE
3. DATE OF ISSUE
G. HAVE YOU FAILED A TEST FOR THIS LICENSE OR RATING?
1.
Yes
2.
2.
WRITTEN TEST
3.
SKILL TEST
4.MEDICAL EXAMINER
No
H. APPLICANT’S CERTIFICATION— I certify that all statements and answers provided by me on this application form are complete and true to the best of my knowledge and I agree that they
are to be considered as part of the basis for issuance of any PEL license to me.
1. DATE
2. APPLICANT SIGNATURE:
A person shall not with intent to deceive: (c) make any false
representation for the purpose of procuring for himself or any other
person the grant, issue, renewal or variation of any such license...
CAAP Form 542 [3]2016
Control Number
1
APPLICATION FOR
AIRMAN PERSONAL LICENSE
[OTHER THAN FLIGHT CREWMEMBERS]
INSTRUCTIONS
Print or type. Submit original only to the Flight Standards
Inspectorate Service or a CAAP Authorized Person. If
additional space is required, use an attachment
H. AUTHORIZED PERSON’S REPORT
1.
I have personally reviewed this applicant’s experience and/or training records, and certify that the individual meets the pertinent requirements of PCAR Part 2 for
the license or rating sought.
(a). License or Rating for Which Tested
(b). Date
(c). Examiner’s Signature (Sign)
(d). License No.
(f). Designation Expires
(g). Examiner’s Name (Print Name)
(e). Designation No.
2.
I have personally conducted the skill test of this applicant in accordance with pertinent procedures and standards with the results indicated below.
a.
Approved – License Issued
c. Location of Test
d. Duration
b.
Disapproved – Disapproval Notice Issued
e. License or Rating for Which Tested
f. Date
g. Examiner’s Signature (Sign)
h. License No.
j. Designation Expires
k. Examiner’s Name (Print Name)
i. Designation No.
I. ATTACHMENTS:
1.
Language Proficiency Report
6.
Airman’s Identification (ID)
2.
Knowledge Test Report
7.
Medical Certificate
11.
3.
Skill Test Report & Flight Plan
8.
NTC License
12.
4.
Notice of Disapproval
9.
13.
5.
Superseded Airman Certificate
10.
14.
J. CAAP AUTHORIZED PERSON CERTIFICATION:
1. THE LICENSE(S) WAS ISSUED I/A/W PCAR 2 AND CAAP REQUIRMENTS:
3. DATE
4. TITLE OR DESIGNATION NUMBER
2. THE LICENSE WAS NOT ISSUED
5. SIGNATURE
6. CASORT-PEL Entry:
K. NOTES:
CAAP Form 542 [3]2016
Control Number
