050-statement-of-qualification-dar-der-dme

gaca_gov_sa · form · processed · 2 chunks

GACA
ال necesita للطيران المدني
General Authority of Civil Aviation
[Non-Text]
STATEMENT OF QUALIFICATION
(DAR-DER-DME)
<table><tr><td colspan="4">1. Name of Applicant or Organization</td><td colspan="2">3. Nationality</td></tr><tr><td colspan="4"></td><td colspan="2"></td></tr><tr><td colspan="4">2. Business Address</td><td colspan="2">4. ID Number</td></tr><tr><td rowspan="3" colspan="4"></td><td colspan="2"></td></tr><tr><td colspan="2">5. Date of Birth</td></tr><tr><td colspan="2"></td></tr><tr><td>Phone</td><td></td><td>Email</td><td colspan="2"></td><td>Fax</td></tr><tr><td colspan="6">6. Designation Sought</td></tr><tr><td rowspan="4" colspan="3">□ Designated Engineering Representative (DER)</td><td colspan="2">□ Structure Engineering</td><td>□ Engine Engineering</td></tr><tr><td colspan="2">□ Power Engineering</td><td>□ Propeller Engineering</td></tr><tr><td colspan="2">□ System &amp; Equipment Engineering</td><td>□ Flight Analyst</td></tr><tr><td colspan="2">□ Acoustical Engineering</td><td>□ Flight Test Pilot</td></tr><tr><td rowspan="3" colspan="3">□ Designated Airworthiness Representative (DAR)</td><td colspan="2">□ Manufacturing Functions</td><td rowspan="3">NOTE:A separate application may Be submitted for each Function i.e. Manufacturing, Engineering, Maintenance.</td></tr><tr><td colspan="2">□ Engineering Functions</td></tr><tr><td colspan="2">□ Maintenance Functions</td></tr><tr><td rowspan="3" colspan="3">□ Designated Mechanics Examiner (DME)</td><td colspan="2">□ Airframe</td><td></td></tr><tr><td colspan="2">□ Powerplant</td><td></td></tr><tr><td colspan="2">□ Airframe and Powerplant</td><td></td></tr></table>
DAR APPLICANTS SHALL IDENTIFY SPECIFIC FUNCTIONS, FOR WHICH DESIGNATION IS SOUGHT:
<table><tr><td colspan="6">7. Experience Resume For Number of Years Pertinent To Designation Sought (Use Additional Sheets If Necessary)</td></tr><tr><td colspan="2">Period</td><td rowspan="2" colspan="2">Employer&#x27;s Name</td><td rowspan="2" colspan="2">Position Title and Duties</td></tr><tr><td>From</td><td>To</td></tr><tr><td></td><td></td><td colspan="2"></td><td colspan="2"></td></tr><tr><td colspan="6">8. Education and Training High School “ O” Level and Above Pertinent To Designation Sought</td></tr><tr><td colspan="2">Period</td><td rowspan="2">Name of School</td><td rowspan="2">Curriculum or Study Program</td><td rowspan="2" colspan="2">Degree Received</td></tr><tr><td>From</td><td>From</td></tr><tr><td></td><td></td><td></td><td></td><td colspan="2"></td></tr><tr><td colspan="6">9.GACA/FAA Certificates Now Held Pertinent To Designation Sought</td></tr><tr><td colspan="2">Type</td><td>Certificate Number</td><td>Rating</td><td colspan="2">Date Each Rating Issued</td></tr><tr><td colspan="2"></td><td></td><td></td><td colspan="2"></td></tr><tr><td colspan="6">10. Employer&#x27;s Recommendation (To Be Completed For DER Only) I RECOMMEND THE PERSON IDENTIFIED ABOVE TO BE APPOINTED AS DESIGNATED ENGINEERING REPRESENTATIVE</td></tr><tr><td colspan="3">Primary Business</td><td colspan="2">Signature</td><td>Date</td></tr><tr><td colspan="3"></td><td colspan="2"></td><td></td></tr><tr><td colspan="6">11. Location Where Designated Functions Will Be Performed</td></tr><tr><td colspan="3">Address</td><td colspan="3">Telephone No</td></tr><tr><td colspan="3"></td><td colspan="3"></td></tr><tr><td colspan="6">12. Certification: I certify that the above statements are true to the best of my knowledge and that I am familiar with GACA Regulations Pertinent to the designation sought.</td></tr><tr><td colspan="3">Signature</td><td colspan="2">Date</td><td></td></tr><tr><td colspan="3"></td><td colspan="3"></td></tr></table>
GACA-AVSES-AIR-F050
Rev: 3, Date: 03 Sep 25
Page 1 of 2

GACA
العلوميه العامه للطيران المدني
General Authority of Civil Aviation
[Non-Text]
STATEMENT OF QUALIFICATION
(DAR-DER-DME)
<table><tr><td colspan="6">13. Action Record (For GACA Use Only)</td></tr><tr><td colspan="3">Designee&#x27;s Name/Organization Name</td><td colspan="3">Designation Number</td></tr><tr><td colspan="3"></td><td colspan="3"></td></tr><tr><td colspan="3">Date Applicant Interviewed</td><td colspan="3">Date Certificate of Designation Expires</td></tr><tr><td colspan="3"></td><td colspan="3"></td></tr><tr><td colspan="3">Date References Verified</td><td colspan="3">Signature of Approving Authority</td></tr><tr><td colspan="3"></td><td rowspan="4" colspan="3"></td></tr><tr><td colspan="3">Date Applicant Notified</td></tr><tr><td colspan="3"></td></tr><tr><td>□ Accepted</td><td></td><td>□ Rejected</td></tr><tr><td colspan="6">14. Record of Approval</td></tr><tr><td rowspan="4" colspan="3">□ Designated Engineering Representative (DER)</td><td>□ Structure Engineering</td><td>□ Engine Engineering</td></tr><tr><td>□ Power plant Engineering</td><td>□ Propeller Engineering</td></tr><tr><td>□ System &amp; Equipment Engineering</td><td>□ Flight Analyst</td></tr><tr><td>□ Acoustical Engineering</td><td>□ Flight Test Pilot</td></tr><tr><td rowspan="3" colspan="3">□ Designated Airworthiness Representative (DAR)</td><td>□ Manufacturing Functions</td><td rowspan="3" colspan="2">NOTE :A Separate Approval Is Required For Each Discipline.</td></tr><tr><td>□ Engineering Functions</td></tr><tr><td>□ Maintenance Functions</td></tr><tr><td rowspan="3" colspan="3">□ Designated Mechanics Examiner (DME)</td><td colspan="3">□ Airframe</td></tr><tr><td colspan="3">□ Powerplant</td></tr><tr><td colspan="3">□ Airframe and Powerplant</td></tr><tr><td colspan="6">Functions Authorized (Identify Specific Functions Authorized, Including Any Limitation)</td></tr><tr><td colspan="6"></td></tr><tr><td colspan="6">15. Record of Subsequent Actions</td></tr><tr><td colspan="3">Type</td><td rowspan="2">New Address and Telephone Number (If Changed)</td><td rowspan="2">Date Status of Designee Changed</td><td rowspan="2">GACA Official</td></tr><tr><td>Annual Renewal</td><td>Change of Address</td><td>Cancellation</td></tr><tr><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td></td><td>-</td><td></td><td></td><td></td><td></td></tr><tr><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td></td><td></td><td></td><td></td><td>-</td><td></td></tr><tr><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>-</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td></td><td></td><td></td><td>-</td><td></td><td></td></tr></table>
GACA-AVSES-AIR-F050
Rev: 3, Date: 03 Sep 25
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