gaca_gov_sa · form · processed · 3 chunks
GACA المنيه العامه للطيران المدني General Authority of Civil Aviation [Non-Text] EXAMINER DESIGNATION AND QUALIFICATION RECORD <table><tr><td colspan="10">Type Of Designation</td></tr><tr><td>□</td><td colspan="2">Private Pilot Examiner</td><td>□</td><td colspan="3">Commercial Pilot Examiner</td><td colspan="3">Airline Transport Pilot</td></tr><tr><td>□</td><td colspan="2">Proficiency Pilot Examiner</td><td>□</td><td colspan="3">Flight Engineer Examiner</td><td colspan="3">Flight Instructor Examiner</td></tr><tr><td>□</td><td colspan="9">Other</td></tr><tr><td colspan="10">Attach supplemental sheets if more space is required for any item</td></tr><tr><td colspan="6">1. NAME (First, middle, last)</td><td colspan="4">Telephone No.</td></tr><tr><td colspan="6">2. NATIONAL ADDRESS(Building No., street, neighborhood, city, postal code and additional No.</td><td colspan="2">3. DATE OF BIRTH(Day, month, and year)</td><td colspan="2">4. S.A. CITIZEN</td></tr><tr><td rowspan="2" colspan="8"></td><td>□ YES</td></tr><tr><td>□ NO</td></tr><tr><td colspan="10">5. DO YOU NOW HOLD, OR HAVE YOU EVER HELD, AN EXAMINER DESIGNATION</td></tr><tr><td colspan="10">□ YES □ NO</td></tr><tr><td colspan="10">Type and number</td></tr><tr><td colspan="10">6. HAS ANY CERTIFICATE OR RATING ISSUED YOU EVER BEEN SUSPENDED OR REVOKED OR HAVE YOU PAID A CIVIL PENALTY AS A RESULT OF A VIOLATION OF THE GACA REGULATIONS.(Complete for original designations only)</td></tr><tr><td>□ YES</td><td rowspan="2" colspan="9"></td></tr><tr><td>□ NO</td></tr><tr><td colspan="10">7. CERTIFICATES HELD</td></tr><tr><td colspan="2">Type</td><td colspan="4">Certificate No.</td><td colspan="3">Ratings</td><td colspan="2">Date Issued</td></tr><tr><td colspan="2"></td><td colspan="4"></td><td colspan="3"></td><td colspan="2"></td></tr><tr><td colspan="10">8. FLIGHT EXPERIENCE (in hours)</td></tr><tr><td rowspan="2" colspan="2"></td><td colspan="2">AIRPLANE</td><td colspan="2">ROTORTYPE</td><td colspan="2">GLIDERS</td><td colspan="2">AIRSHIPS</td><td rowspan="2">INSTRUMENT FLIGHT (Actual or sim)</td></tr><tr><td>TOTAL</td><td>LAST 12 MO</td><td>TOTAL</td><td>LAST 12 MO</td><td>TOTAL</td><td>LAST 12 MO</td><td>TOTAL</td><td>LAST 12 MO</td></tr><tr><td colspan="2">PILOT-IN-COMMAND</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td colspan="2">FLIGHT INSTRUCTION GIVEN</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td colspan="2">COPILOT</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td colspan="2">FLIGHT NAVIGATOR</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td colspan="2">FLIGHT ENGINEER</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td colspan="11">9. EMPLOYMENT (Indicate professional experience pertinent to this designation)</td></tr><tr><td colspan="3">Employer's Name</td><td colspan="3">Nature Of Work</td><td colspan="2">Dates</td><td colspan="3">Title Of Position</td></tr><tr><td colspan="3"></td><td colspan="3"></td><td colspan="2"></td><td colspan="3"></td></tr><tr><td colspan="11">10. SPECIAL TRAINING PERTINENT TO THE DESIGNATION</td></tr><tr><td colspan="11">CERTIFICATION: I certify that I am familiar with the requirements for this designation, its privileges and limitations, and that the information stated herein is true. It is understood that this designation may be terminated upon notice by the GACA for reasons specified in section 183.15(b) of the General Authority of Civil Aviation Regulations.</td></tr><tr><td colspan="3">Date</td><td colspan="3"></td><td colspan="5">Signature</td></tr><tr><td colspan="3"></td><td colspan="3"></td><td colspan="5"></td></tr></table> GACA-AVSES-OPS-F049 Rev: 3, Date: 19 Jun 25 Page 1 of 3 GACA المنيه العامه للطيران المدني General Authority of Civil Aviation [Non-Text] EXAMINER DESIGNATION AND QUALIFICATION RECORD <table><tr><td colspan="9">FOR GACA USE</td></tr><tr><td colspan="3">Type Of Action</td><td rowspan="2" colspan="6">Flight Test Activities-General Aviation(Complete for renewals and additional designations)</td></tr><tr><td>□</td><td colspan="2">Original Issuance</td></tr><tr><td>□</td><td colspan="2">Renewal</td><td colspan="6"></td></tr><tr><td>□</td><td colspan="2">Additional Authority</td><td colspan="6"></td></tr><tr><td>□</td><td colspan="2">Spot Check Only- No Renewal Effected</td><td colspan="6">Date Last Report Submitted</td></tr><tr><td>□</td><td colspan="2">Reinstatement</td><td colspan="6"></td></tr><tr><td colspan="2">Certificates/Ratings</td><td>Total Submitted</td><td>Disapproved By Examiner</td><td colspan="2">Accepted By Inspector</td><td colspan="2">Rechecked By Inspector</td><td>No. Returned for Correction</td></tr><tr><td colspan="2">Private Pilot</td><td></td><td></td><td colspan="2"></td><td colspan="2"></td><td></td></tr><tr><td colspan="2">Commercial Pilot</td><td></td><td></td><td colspan="2"></td><td colspan="2"></td><td></td></tr><tr><td colspan="2">Airline Transport Pilot</td><td></td><td></td><td colspan="2"></td><td colspan="2"></td><td></td></tr><tr><td colspan="2">Instrument Rating</td><td></td><td></td><td colspan="2"></td><td colspan="2"></td><td></td></tr><tr><td rowspan="3">Additional Ratings</td><td>Private</td><td></td><td></td><td colspan="2"></td><td colspan="2"></td><td></td></tr><tr><td>Commercial</td><td></td><td></td><td colspan="2"></td><td colspan="2"></td><td></td></tr><tr><td>ATR</td><td></td><td></td><td colspan="2"></td><td colspan="2"></td><td></td></tr><tr><td colspan="9">Character and Reputation(Include industry and community reputation as well as personal knowledge possessed by GACA personnel)</td></tr><tr><td colspan="9"></td></tr><tr><td colspan="9">Professional Ability(Brief narrative description of examiner indoctrination and training given and results expressed as "good," excellent or "unsatisfactory.")</td></tr><tr><td colspan="9"></td></tr><tr><td colspan="9">Complete for original issuance and reinstatements only</td></tr><tr><td colspan="5">Inspector's Recommendation/Action</td><td>□</td><td>Approve</td><td>□</td><td>Disapprove</td></tr><tr><td colspan="9">Justification For Approval/Reasons for Disapproval</td></tr><tr><td colspan="9"></td></tr><tr><td colspan="9">The individual named has been flight tested/examined and deemed competent to perform the duties of the designation indicated below.</td></tr><tr><td colspan="9">Designation</td></tr><tr><td>□</td><td colspan="2">Private Pilot</td><td>□</td><td colspan="2">Commercial Pilot Examiner</td><td>□</td><td colspan="2">Airline Transport Pilot Examiner</td></tr><tr><td>□</td><td colspan="2">Proficiency Pilot Examiner</td><td>□</td><td colspan="2">Flight Engineer Examiner</td><td>□</td><td colspan="2">Flight Instructor Examiner</td></tr><tr><td colspan="9">Category</td></tr><tr><td>□</td><td colspan="2">AIRPLANE</td><td>□</td><td colspan="2">ROTORCRAFT</td><td>□</td><td>GLIDER</td><td>□ AIRSHIP</td></tr><tr><td colspan="9">Additional Qualifications Limitations (For pilot flight engineer examiner give aircraft category)</td></tr><tr><td colspan="9"></td></tr><tr><td colspan="2">Date</td><td colspan="2">Credential No.</td><td colspan="3">Inspector's Name</td><td colspan="2">Signature</td></tr><tr><td colspan="2"></td><td colspan="2"></td><td colspan="3"></td><td colspan="2"></td></tr><tr><td colspan="9">The information on this form is solicited under authority of the General Authority of Civil Aviation Regulations Part 183. The purpose of this information is to establish your qualifications as an examiner. Submission of the data is mandatory. Incomplete submission may result in delay or denial of your request. The data will be used to determine your eligibility as an examiner, and for statistical purposes.</td></tr></table> GACA-AVSES-OPS-F049 Rev: 3, Date: 19 Jun 25 Page 2 of 3 GACA الهييه العامه للطيران المدني General Authority of Civil Aviation [Non-Text] EXAMINER DESIGNATION AND QUALIFICATION RECORD <table><tr><td colspan="6">GACA SELECTION BORD</td></tr><tr><td>□ Approved</td><td rowspan="2">Date</td><td rowspan="2"></td><td rowspan="2">Signature</td><td rowspan="2" colspan="2"></td></tr><tr><td>□ Disapprove</td></tr><tr><td colspan="3">Type Of Designation</td><td colspan="3">Certificate Of Authority Issued</td></tr><tr><td rowspan="2" colspan="3"></td><td>No.</td><td>To Serve Under</td><td>Expiration Date</td></tr><tr><td></td><td></td><td></td></tr></table> GACA-AVSES-OPS-F049 Rev: 3, Date: 19 Jun 25 Page 3 of 3