014-airman-certificate-and-or-rating-application

gaca_gov_sa · form · processed · 4 chunks
document_type=form entity=language:ar entity=format:application/pdf language=en taxonomy_l1=transport taxonomy_l2=aviation taxonomy_l3=aircraft_certification validity=valid validity_confidence=0.6
GACA
الهييه العامه للطيران المدني
General Authority of Civil Aviation
[Non-Text]
AIRMAN CERTIFICATE AND/OR RATING APPLICATION
<table><tr><td colspan="6">I. APPLICATION INFORMATION</td><td colspan="2">GACA Certificate No.</td><td rowspan="6" colspan="3">PHOTO3 x 3 cmWhite background with no head cover.</td></tr><tr><td>□ Initial</td><td colspan="2">□ Renewal</td><td colspan="3">□ Additional Rating</td><td rowspan="4" colspan="2"></td></tr><tr><td>□ Reissuance</td><td colspan="2">Reason:</td><td colspan="3"></td></tr><tr><td>□ MECHANIC</td><td colspan="2"></td><td rowspan="2" colspan="3">□ REPAIRMAN(Specify Rating)</td></tr><tr><td>□ AIRFRAME</td><td colspan="2"></td></tr><tr><td>□ POWERPLANT</td><td colspan="2"></td><td colspan="3"></td><td colspan="2"></td></tr><tr><td colspan="3">A. Name (First, Middle, Last)</td><td colspan="2">B. Saudi ID/Iqama No.</td><td>C. Passport No.</td><td colspan="2">D. Date of Birth</td></tr><tr><td colspan="3">E. Address</td><td colspan="2"></td><td colspan="2">F. Place of Birth</td><td colspan="2">G. Country of Citizenship</td></tr><tr><td>Street</td><td colspan="2">House</td><td colspan="2"></td><td colspan="2"></td><td colspan="2"></td></tr><tr><td>City</td><td colspan="2">State/Province</td><td colspan="2"></td><td colspan="4">H. Do you read, speak, write, &amp; understand the English language?</td></tr><tr><td>Country</td><td colspan="2">Postal Code</td><td colspan="2"></td><td colspan="2">□ Yes</td><td colspan="2">□ No</td></tr><tr><td>Phone (Land)</td><td colspan="2">Mobile</td><td colspan="2"></td><td>I. Height (cm)</td><td>J. Weight (kg)</td><td>K. Hair</td><td>L. Eyes M. Sex</td></tr><tr><td>Email</td><td colspan="2"></td><td colspan="2"></td><td></td><td></td><td></td><td></td></tr><tr><td colspan="3">N. Do you now hold, or have you ever held a GACA Airman Certificate?</td><td colspan="2">O. Type of Certificate</td><td colspan="2">P. Certificate Number</td><td>Q. Issue Date</td><td>R. Expiry Date</td></tr><tr><td colspan="2">□ Yes</td><td colspan="2">□ No</td><td colspan="2"></td><td></td><td></td><td></td></tr><tr><td colspan="3">S. Have you ever had an Airman certificate suspended or revoked?</td><td colspan="2">□ Yes</td><td colspan="4">(If &quot;Yes&quot; explain below. Continue on a separate sheet, if more space needed)</td></tr><tr><td colspan="7">T. Have you ever been convicted for violation of any statutes related to psychoactive substances?</td><td colspan="2">U. Date of Final Conviction</td></tr></table>
II. CERTIFICATE OR RATING APPLIED FOR ON BASIS OF
<table><tr><td colspan="2">□ A. Civil Experience</td><td colspan="2">□ B. Military Experience</td><td colspan="4">□ C. Letter of Recommendation for Repairman</td></tr><tr><td rowspan="2">□</td><td rowspan="2">D. Graduate of Approved School</td><td colspan="3">1. School Name</td><td colspan="3">2. School Location</td></tr><tr><td colspan="3">3. School No.</td><td colspan="2">4. Curriculum from which graduated</td><td>5. Graduation Date</td></tr><tr><td rowspan="2">□</td><td rowspan="2">E. Student has made satisfactory progress and is recommended to take the Oral/Practical test (GACA/GACAR 66.67)</td><td colspan="3">1. School Name</td><td colspan="3">2. School Location</td></tr><tr><td colspan="2">3. School No.</td><td colspan="4">4. School Official Name / Signature</td></tr><tr><td colspan="2">□</td><td>F. Special Authorization to take Mechanic&#x27;s Oral/Practical test (GACA/GACAR 66.67)</td><td colspan="2">1. Date Auth.</td><td>2. Date Auth. Expires</td><td colspan="3">3. GACA Inspector Name / Signature</td></tr><tr><td rowspan="2">□</td><td rowspan="2">G. Holder of Foreign License/Certificate</td><td colspan="2">1. Country</td><td colspan="2">2. Type of License</td><td>3. Number</td><td>4. Issue Date</td><td>5. Expiry Date</td></tr><tr><td colspan="4">6. Ratings</td><td colspan="3">7. Limitation</td></tr></table>
III. RECORD OF WORK EXPERIENCE AND TRAINING
<table><tr><td colspan="2">A. Military Competence Obtained In</td><td colspan="2">(1) Service</td><td colspan="2">(2) Rank Or Pay Level</td><td colspan="2">(3) Military Specialty Code</td></tr><tr><td colspan="8"></td></tr><tr><td colspan="8">B. Applicants Other Than GACA Certificated School Graduates. List Experience And Training Related To Certificate And Rating Applied For.Continue On A Separate Sheet, If More Space Needed).</td></tr><tr><td colspan="2">Dates (Month And Year)</td><td rowspan="2" colspan="3">Type Work Performed</td><td rowspan="2" colspan="2">Employer</td><td rowspan="2">Location</td></tr><tr><td>From</td><td>To</td></tr><tr><td></td><td></td><td colspan="3"></td><td colspan="2"></td><td></td></tr><tr><td></td><td></td><td colspan="3"></td><td colspan="2"></td><td></td></tr><tr><td colspan="2">Dates (Month And Year)</td><td rowspan="2" colspan="3">Aviation Training</td><td rowspan="2" colspan="2">Organization</td><td rowspan="2">Location</td></tr><tr><td>From</td><td>To</td></tr><tr><td></td><td></td><td colspan="3"></td><td colspan="2"></td><td></td></tr><tr><td></td><td></td><td colspan="3"></td><td colspan="2"></td><td></td></tr><tr><td colspan="8">IV. Have you failed a test for this certificate or rating? ☐ Yes ☐ No</td></tr></table>
V. 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 the issuance of any GACA certificate to me. I understand that willful false statements made on this form my result in legal action under the laws of the Kingdom of Saudi Arabia. I certify that copies of documents provided are true copies of original documents which I have reviewed.
<table><tr><td>Name</td><td></td><td>Signature</td><td></td><td>Date</td><td></td></tr></table>
VI. EMPLOYER/SPONSOR
<table><tr><td>Address</td><td colspan="2"></td><td>Tel No.</td><td colspan="2"></td></tr><tr><td>Email</td><td colspan="2"></td><td>Title</td><td colspan="2"></td></tr><tr><td>Name</td><td colspan="2"></td><td>Official Seal</td><td colspan="2"></td></tr><tr><td>Signature</td><td colspan="2"></td><td></td><td colspan="2"></td></tr></table>
VII. I FIND THIS APPLICANT MEETS THE REQUIREMENTS OF GACA/FAR 65 AND IT IS ELIGIBLE TO TAKE THE REQUIRED TESTS
<table><tr><td>Date</td><td>Inspector Name</td><td>Inspector No.</td><td>Inspector Signature</td></tr><tr><td></td><td></td><td></td><td></td></tr></table>
GACA-AVSES-AIR-F014
Rev: 3, Date: 15 Jul 25
Page 1 of 2

GACA
ال necesita للطيران المدني
General Authority of Civil Aviation
[Non-Text]
AIRMAN CERTIFICATE AND/OR RATING APPLICATION
<table><tr><td colspan="9">RESULTS OF KNOWLEDGE TESTS</td><td colspan="2">REMARKS</td></tr><tr><td colspan="3">GENERAL</td><td colspan="3">AIRFRAME</td><td colspan="5">POWERPLANT</td></tr><tr><td>Date</td><td></td><td></td><td>Date</td><td></td><td></td><td>Date</td><td></td><td></td><td></td><td></td></tr><tr><td>Take</td><td></td><td></td><td>Take</td><td></td><td></td><td>Take</td><td></td><td></td><td></td><td></td></tr><tr><td>Score</td><td></td><td></td><td>Score</td><td></td><td></td><td>Score</td><td></td><td></td><td></td><td></td></tr><tr><td colspan="11">RESULTS OF ORAL AND PRACTICAL TESTS</td></tr><tr><td colspan="11">MECHANIC</td></tr><tr><td colspan="11">I. GENERAL - Airframe and Powerplant</td></tr><tr><td>ORAL TEST</td><td></td><td>□ PASS</td><td></td><td>Expiration Date</td><td></td><td></td><td></td><td></td><td>□ FAIL</td><td></td></tr><tr><td>QUES. NO.</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>PRACTICAL TEST</td><td></td><td>□ PASS</td><td></td><td>Expiration Date</td><td></td><td></td><td></td><td></td><td>□ FAIL</td><td></td></tr><tr><td>PROJECT NO.</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td colspan="11">II. AIRFRAME STRUCTURES</td></tr><tr><td>ORAL TEST</td><td></td><td>□ PASS</td><td></td><td>Expiration Date</td><td></td><td></td><td></td><td></td><td>□ FAIL</td><td></td></tr><tr><td>QUES. NO.</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>PRACTICAL TEST</td><td></td><td>□ PASS</td><td></td><td>Expiration Date</td><td></td><td></td><td></td><td></td><td>□ FAIL</td><td></td></tr><tr><td>PROJECT NO.</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td colspan="11">III. AIRFRAME SYSTEMS AND COMPONENTS</td></tr><tr><td>ORAL TEST</td><td></td><td>□ PASS</td><td></td><td>Expiration Date</td><td></td><td></td><td></td><td></td><td>□ FAIL</td><td></td></tr><tr><td>QUES. NO.</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>PRACTICAL TEST</td><td></td><td>□ PASS</td><td></td><td>Expiration Date</td><td></td><td></td><td></td><td></td><td>□ FAIL</td><td></td></tr><tr><td>PROJECT NO.</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td colspan="11">IV. POWERPLANT THEORY AND MAINTENANCE</td></tr><tr><td>ORAL TEST</td><td></td><td>□ PASS</td><td></td><td>Expiration Date</td><td></td><td></td><td></td><td></td><td>□ FAIL</td><td></td></tr><tr><td>QUES. NO.</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>PRACTICAL TEST</td><td></td><td>□ PASS</td><td></td><td>Expiration Date</td><td></td><td></td><td></td><td></td><td>□ FAIL</td><td></td></tr><tr><td>PROJECT NO.</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td colspan="11">V. POWERPLANT SYSTEMS AND COMPONENTS</td></tr><tr><td>ORAL TEST</td><td></td><td>□ PASS</td><td></td><td>Expiration Date</td><td></td><td></td><td></td><td>□ FAIL</td><td></td><td></td></tr><tr><td>QUES. NO.</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>PRACTICAL TEST</td><td></td><td>□ PASS</td><td></td><td>Expiration Date</td><td></td><td></td><td></td><td>□ FAIL</td><td></td><td></td></tr><tr><td>PROJECT NO.</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td colspan="11">AIRMAN&#x27;S IDENTIFICATION</td></tr><tr><td>Form of ID</td><td colspan="3"></td><td colspan="2">Date of Birth</td><td colspan="2"></td><td colspan="2">Email Address</td><td></td></tr><tr><td>ID Number</td><td colspan="3"></td><td colspan="2">Expiration Date</td><td colspan="2"></td><td colspan="2">Telephone Number</td><td></td></tr><tr><td colspan="11">DESIGNATED EXAMINER&#x27;S REPORT</td></tr><tr><td colspan="11">I have personally tested this applicant in accordance with pertinent procedures and standards, and I have indicated the result as:</td></tr><tr><td colspan="4">□ APPROVED (Temporary Certificate Issued)</td><td colspan="7">□ APPROVED (Temporary Certificate NOT Issued)</td></tr><tr><td colspan="2">Attachments</td><td colspan="3">□ Report Of Written Test</td><td colspan="3">□ Superseded Certificate</td><td colspan="2">□ Temporary Certificate</td><td>□ Letter</td></tr><tr><td colspan="2">Date Test Completed</td><td colspan="4">Examiner&#x27;s Name</td><td colspan="4">Signature</td><td>Designation No.</td></tr><tr><td colspan="2"></td><td colspan="4"></td><td colspan="4"></td><td></td></tr><tr><td colspan="11">APPLICANT&#x27;S CERTIFICATION</td></tr><tr><td colspan="11">This Block Must Be Completed By The Applicant At The Time Of Issuance Of Temporary Certificate</td></tr><tr><td colspan="11">Have You Ever Had An Airman Certificate Suspended or Revoked? □ Yes □ No</td></tr><tr><td colspan="11">Have You Ever Been Convicted For Violation Of Any Statutes Related To Psychoactive Substances? □ Yes □ No</td></tr><tr><td colspan="11">Date of Final Conviction I Certify That The Statements By Me Are True Signature Date</td></tr><tr><td colspan="11">GACA INSPECTOR&#x27;S REPORT</td></tr><tr><td colspan="11">I Have Personally Examined This Applicant&#x27;s Papers □ With The Indicated Result □ ApproveD □ Tested This Applicant In Accordance With Pertinent Procedures And Standards □ Disapproved □ Disapproval</td></tr><tr><td>Date</td><td colspan="4">Inspector&#x27;s Signature</td><td colspan="5">Inspector Name (Print Name)</td><td>Inspector Number</td></tr><tr><td></td><td colspan="4"></td><td colspan="5"></td><td></td></tr><tr><td colspan="11">FILE ATTACHMENTS AS APPLICABLE</td></tr><tr><td colspan="11">□ Copy - Foreign License/Certificate (if applicable) □ Copy/original Knowledge Test Report(s) (as applicable) □ Copy - GACA Airman Certificate (if applicable)□ Copy - Airman ID □ Evidence of required Experience (if applicable) □ Copy - Temporary Airman Certificate (if applicable)□ Copy - Valid Airman Passport □ Copy - Official Course Completion Certificate (s) (if applicable) □ Superseded Airman Certificate (if applicable)□ Copy - Official Receipt of Payment (if applicable) □ Copy - Prior Employment verification (if applicable) □ Evidence of required Training (if applicable)</td></tr></table>
GACA-AVSES-AIR-F014
Rev: 3, Date: 15 Jul 25
Page 2 of 2