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541 Application for Airman Personal License (Flight Crew Member)
CAAP Airman Personal License Application forms
Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: CAAP Form 541 [1]2012
APPLICATION FOR
AIRMAN PERSONAL LICENSE
[FLIGHT CREW MEMBER]
A. APPLICATION IS HEREBY MADE FOR
ISSUANCE
REISSUANCE
INSTRUCTIONS
Print or type. These are for CAAP use only. Submit original
only to the Flight Standards Inspectorate or a CAAP Authorized
Person. If additional space is required, use an attachment
ADDITIONAL
RENEWAL OF THE FOLLOWING PHILIPPINE PEL LICENSE:
1.
STUDENT PILOT
3.
COMMERCIAL PILOT
5.
FLIGHT ENGINEER
7.
FLIGHT NAVIGATOR
2.
PRIVATE PILOT
4.
AIRLINE TRANSPORT PILOT
6.
FLIGHT INSTRUCTOR
8.
OTHER:
B. LICENSE OR RATING APPLIED FOR ON BASIS OF:
2. AIRCRAFT TO BE USED (if flight test required)
1.COMPLETION OF REQUIRED
WRITTEN AND/OR PRACTICAL TEST
3. TOTAL TIME IN THIS AIRCRAFT/SIM/FTD
hours
4. PILOT-IN-COMMAND
hours
C. THE FOLLOWING CATEGORY AND/OR CLASS IS INVOLVED:
1.
AEROPLANE – SINGLE ENGINE LAND
5.
GLIDER……........................(SPECIFY TOW)
2.
AEROPLANE – MULTIENGINE LAND
6.
ROTORCRAFT……............(SPECIFY CLASS)
3.
AEROPLANE – SINGLE ENGINE SEA
7.
LIGHTER THAN AIR. ...... .(SPECIFY CLASS))
4.
AEROPLANE – MULTIENGINE SEA
8.
POWERED LIFT
D. THE FOLLOWING RATING IS INVOLVED:
1.
INSTRUMENT
3.
ADDED TYPE RATING……….....(SPECIFY)
2.
CATEGORY II OR III APPROACHES
4.
OTHER RATING……..................(SPECIFY)
E. AIRMAN PERSONAL INFORMATION:
1. NAME (Last, First, Middle)
2. PERMANENT ADDRESS (Street or PO Box Number)
3. TELEPHONE AND FAX
4. CITY
5. DATE OF BIRTH (DAY,MONTH, YEAR)
6. AGE
7. PLACE OF BIRTH
10. HEIGHT
12. HAIR
13. EYES
ISLAND/STATE/PROVINCE
11. WEIGHT
cms
MAIL CODE
8. NATIONALITY (CITIZENSHIP)
14. SEX
COUNTRY
9. Language
Proficiency
Level 4/+?
15. E-MAIL ADDRESS
Yes
No
16. PEL NO.
kgs
F. RECORD OF PILOT TIME
Instruction
Total
Received
Solo
Pilot
In
Command
(PIC)
Cross
Country
Instruction
Received
Cross
Country
Solo
Cross
Country
PIC
Instrument
Night
Instruction
Received
Night
Take-Off/
Landing
Night
PIC
Night
Take-Off/
Landing
PIC
Number
Of
Flights
Number
Of
AeroTows
Number
Of
Ground
Launches
Number
Of
Power
Launches
Gliders
Free
Balloon
Airship
Airplane
PIC
PIC
SIC
SIC
SIC
PIC
PIC
PIC
PIC
SIC
SIC
SIC
SIC
PIC
PIC
PIC
PIC
SIC
Powered
Lift
PIC
SIC
Rotorcraft
PIC
SIC
SIC
SIC
Simulator
Training
Device
PCATD
G. MEDICAL EVALUATION INFORMATION:
1. CLASS OF CERTIFICATE
2. STATE OF ISSUE
3. DATE OF ISSUE
4.MEDICAL EXAMINER
H. HAVE YOU FAILED A TEST FOR THIS LICENSE OR RATING?
1.
Yes
2.
No
I. 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 Philippines 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...
J. INSTRUCTOR’S RECOMMENDATION
I have personally instructed the applicant and consider this person ready to take the test.
1. Date
2. Instructor’s Signature (Print Name and Sign)
3. License Number
4. License Expires
AFFIDAVIT
REPUBLIC OF THE PHILIPPINES
________________________)S.S.
________________________)
I hereby solemnly swear that the statements contained herein are true. Dated this ____day of ____ 20___.
_____________________________________________
Applicant Signature
SUBSCRIBED AND SWORN to before me on this ___________________day of ____________________affiant having exhibited his/her Government Issued ID
No.__________________________________________________ issued at ________________________on ________________20____
Doc. No. ______________
Page No ______________
Book No. _____________
Series of 20 ___________
Notary Public
Until December 31, 20____:
CAAP Form 541 [1]2012
APPLICATION FOR
AIRMAN PERSONAL LICENSE
[FLIGHT CREW MEMBER]
INSTRUCTIONS
Print or type. These are for CAAP use only. Submit original
only to the Flight Standards Inspectorate or a CAAP Authorized
Person. If additional space is required, use an attachment
K. DESIGNATED EXAMINER’S OR AIRMAN CERTIFICATION REPRESENTATIVE/DCP REPORT
1.
I have personally reviewed this applicant’s pilot logbook and/or training record, and certify that the individual meets the pertinent requirements of PCAR Part 2 and 8 for
the license or rating sought.
(a). Location of Test (Facility, City, Island/State/Province)
(b). Date
2.
(c). Examiner’s Signature (Print Name & Sign)
(d). License No.
(e). Designation No.
(f). Designation Expires
I have personally tested and/or verified this applicant in accordance with pertinent procedures and standards with the results indicated below.
(a).
Approved – Recommend issuance/renewal of License
(b).
Disapproved – Recommend Issuance of Disapproval Notice (Original Attached)
(c). Location of Test (Facility, City, Island/State/Province)
(d). Duration of Test
(2) Simulator/FTD
(1) Ground
(e). License or Rating for Which Tested
(f). Type of Aircraft Used
(h). Date
(j). License No.
(i). Examiner’s Signature (Print Name & Sign)
(g). Registration No
(k). Designation No.
L. EVALUATOR’S RECORD (Use For Private, Commercial, ATP License And/Or Type Ratings):
INSPECTOR
EXAMINER
1. Oral
(3) Flight
(l). Designation Expires
Signature and License Number
Date
2. Approved Simulator/Training Device Check
3. Aircraft Flight Check
M. AVIATION SAFETY INSPECTOR OR PEL LICENSING OFFICER REPORT
I have personally tested this applicant in accordance with or have otherwise verified that this applicant complies with pertinent procedures, standards, policies, and/or necessary
requirements with the result indicated below
1.
Approved
2.
3.
Student Pilot License Issued
7.
Examiner’s Recommendation
8.
Reissue or Exchange of Pilot License
(a)
Accepted
4.
Disapproved – Disapproved Notice Issued (Original Attached)
License or Rating Based
5.
Flight Instructor
(a)
(b)
(b)
Rejected
Approved Course Graduate
Other Approved CAAP Qualification Criteria
6.
(a)
(b)
Ground Instructor
Renewal
Reinstatement
9. Instructor Renewal Based On
(a)
13. Date
(d)
6.
15. Control Number
Training Course
Duties and
Responsibilities
12. Graduation Date
16. CASORT-PEL Entry
Airman’s Identification (ID) checked
1.
Student Pilot Authorization (copy)
7.
Medical Certificate
11.
2.
Knowledge Test Report
8.
NTC License
12.
3.
Temporary Airman License
9.
SSP/VISA (for foreigners)
13.
4.
Notice of Disapproval
10.
5.
Superseded Airman License
K. NOTES:
Test
11. ATO Certificate No.
14. Inspector’s Signature (Print Name & Sign)
N. ATTACHMENTS:
(c)
(b)
10. Training Course (FIRC) Name
Activity
Birth Certificate (for SPA)
14.
English Language Proficiency Result
