028-designated-aircraft-dispatcher-examiner-dade-application-and-qualification

gaca_gov_sa · form · processed · 1 chunks

GACA
المنيه العامه للطيران المدني
General Authority of Civil Aviation
[Non-Text]
DESIGNATED AIRCRAFT DISPATCHER EXAMINER (DADE) AND QUALIFICATION RECORD
<table><tr><td colspan="4">1. Name (last, first, middle)</td><td colspan="2">2. Telephone no.</td></tr><tr><td colspan="3"></td><td colspan="3"></td></tr><tr><td colspan="3">3. Address (number, street, city, state, zip code)</td><td>4. Date of birth (month, day, year)</td><td>5. Nationality</td><td>Saudi</td></tr><tr><td rowspan="2" colspan="3"></td><td rowspan="2"></td><td>6. ID #</td><td></td></tr><tr><td>7. Passport #</td><td></td></tr><tr><td colspan="6">8. Has any certificate or rating been issued to you ever been suspended or revoked or have paid a civil penalty as a result of violation of the General Authority of Civil Aviation regulations. (Complete for original designations only)</td></tr><tr><td>☐ YES</td><td colspan="5">If Yes specify: XXX</td></tr><tr><td>☐ NO</td><td colspan="5"></td></tr><tr><td colspan="6">9. Certificates Held</td></tr><tr><td colspan="2">Type</td><td colspan="2">Certificate Number</td><td>Date Issued</td><td>Date Expire</td></tr><tr><td colspan="2"></td><td colspan="2"></td><td></td><td></td></tr><tr><td colspan="6">10. Experience</td></tr><tr><td colspan="2">Type</td><td colspan="2">From</td><td colspan="2">To</td></tr><tr><td colspan="2">Aircraft Dispatcher Examiner</td><td colspan="2"></td><td colspan="2"></td></tr><tr><td colspan="2">Aircraft Dispatcher Instructor</td><td colspan="2"></td><td colspan="2"></td></tr><tr><td colspan="2">Flight Dispatcher</td><td colspan="2"></td><td colspan="2"></td></tr><tr><td colspan="6">11. Qualifications</td></tr><tr><td colspan="2"></td><td colspan="2"></td><td colspan="2"></td></tr><tr><td colspan="6">12. Special Training Pertinent to The Designation (Indicate the latest recurrent training)</td></tr><tr><td colspan="6">TBD</td></tr><tr><td colspan="6">Certification:I certify that I am familiar with the requirement for this designation, its privileges and limitations, and that the information stated herein is true, it is understood that this designation may be terminated suspended or revoked by the GACA without justifications.</td></tr><tr><td colspan="3">Applicant Name</td><td colspan="2">Signature</td><td>Date</td></tr><tr><td colspan="3"></td><td colspan="2"></td><td></td></tr></table>
<table><tr><td colspan="6">FOR GACA USE</td></tr><tr><td>DADE No.</td><td colspan="5"></td></tr><tr><td>Original Issuance</td><td colspan="5"></td></tr><tr><td>Renewal</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Re-instatement</td><td colspan="5"></td></tr><tr><td colspan="6">The individual named has been examined and deemed component to perform the duties of the designation indicated and Certificate Of Authority Issued</td></tr><tr><td colspan="3">Inspector&#x27;s Signature</td><td colspan="3">Date</td></tr><tr><td colspan="3"></td><td colspan="3"></td></tr></table>
GACA-AVSES-OPS-F028
Rev: 3, Date: 07 Jul 25
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