gaca_gov_sa · form · processed · 9 chunks
GACA العربيه للطيران المجتمع General Authority of Civil Aviation [Non-Text] PILOT CERTIFICATE AND/OR RATING APPLICATION I. APPLICATION INFORMATION (Mark 'X' in all the blocks applicable to the certificate or rating for which you are applying) <table><tr><td colspan="4">Certificates</td><td colspan="4">Ratings</td><td colspan="3">Other Information/Requests</td></tr><tr><td colspan="2">Pilot</td><td>Instructor</td><td colspan="2">Category and/or Class</td><td>Instrument</td><td>Ground Instructor</td><td colspan="2">☐ Initial</td><td colspan="2">☐ Instrument Proficiency Check</td></tr><tr><td rowspan="5">☐ Student☐ Private</td><td>☐ Sport</td><td>☐ Flight</td><td>☐ ASE</td><td>☐ Balloon</td><td>☐ Airplane</td><td>☐ Basic</td><td colspan="2">☐ Renewal</td><td colspan="2">☐ Medical Flight Test</td></tr><tr><td rowspan="4">☐ Commercial☐ ATP</td><td rowspan="4">☐ Ground</td><td>☐ Helicopter</td><td>☐ Land</td><td>☐ Helicopter</td><td>☐ Advanced</td><td colspan="2">☐ Reinstatement</td><td colspan="2">☐ Limitation Removal</td></tr><tr><td>☐ Gyroplane</td><td>☐ Glider</td><td></td><td>☐ Instrument</td><td colspan="2">☐ Reexamination</td><td colspan="2">☐ IPL</td></tr><tr><td>☐ AME</td><td></td><td></td><td></td><td colspan="2">☐ Reissuance</td><td colspan="2"></td></tr><tr><td colspan="4">☐ Added Rating</td><td colspan="2">☐ Flight Review</td><td colspan="2"></td></tr><tr><td colspan="3"></td><td>Type rating</td><td colspan="2"></td><td colspan="5">Specify if other</td></tr><tr><td colspan="3">A. Name (Last, First, Middle)</td><td></td><td>B1. ID/IQAMA No.</td><td colspan="2">B2. Passport No.</td><td colspan="2">C. Date of Birth</td><td colspan="2">D. Place of Birth (City and Country)</td></tr><tr><td colspan="3"></td><td></td><td colspan="2"></td><td colspan="2"></td><td colspan="2"></td><td></td></tr><tr><td colspan="3">E1. Residential Address(Including City, Province, Postal Code, and Country)</td><td colspan="3">E2. Mailing Address(This address will be printed on the permanent airman certificate, if different than block E1.)</td><td colspan="2">F. Citizenship☐ SAUDI☐ Other</td><td colspan="3">G. ELP level & Expiry Date</td></tr><tr><td rowspan="2" colspan="3"></td><td rowspan="2" colspan="3"></td><td colspan="2">Specify if other</td><td colspan="3"></td></tr><tr><td>H. Height (cm)</td><td>I. Weight (kg)</td><td>J. Hair Color</td><td>K. Eye Color</td><td>L. Sex</td></tr><tr><td colspan="3"></td><td colspan="3"></td><td colspan="2"></td><td></td><td></td><td>□ Male□ Female</td></tr><tr><td colspan="4">M. Do you hold, or have you ever held a GACA certificate?</td><td colspan="3">M1. Grade of Certificate</td><td colspan="2">M2. Certificate Number</td><td></td><td>M3. Date Issued</td></tr><tr><td colspan="2">□ Yes</td><td colspan="2">□ No</td><td colspan="3"></td><td colspan="2"></td><td></td><td></td></tr><tr><td colspan="2">N. Do you hold a Medical Certificate?</td><td colspan="3">N1. Class of Medical Certificate</td><td colspan="4">N2. Name of Medical Examiner</td><td></td><td>N3. Date Issued</td></tr><tr><td>□ Yes</td><td colspan="2">□ No</td><td colspan="2"></td><td colspan="4"></td><td></td><td></td></tr><tr><td colspan="10">O. Have you ever been convicted for violation of any statutes relating to narcotic drugs, marijuana, or depressant or stimulant drugs or substances?Do not include alcohol offenses involving motor vehicle mode of transportation</td><td>O1. Date of Final Conviction</td></tr><tr><td colspan="10">□ Yes</td><td>□ No</td></tr><tr><td colspan="11">II. CERTIFICATE OR RATING APPLIED FOR ON BASIS OF</td></tr><tr><td>□ A. Completion of Test or Activity</td><td colspan="3">1. Aircraft to be used (If flight test required)</td><td colspan="4">2. Total time in this aircraft and/ or approved FFS or FTD (hours)</td><td>a. Flight Time</td><td colspan="2">b. As Pilot-in-Command</td></tr><tr><td rowspan="3">□ B. Military Competence or Experience</td><td colspan="3">1. Military Service</td><td colspan="3"></td><td>2. Date Rated in Military</td><td colspan="3">3.Rank or Grade & Service No.</td></tr><tr><td colspan="3">4. List Military aircraft for which you have</td><td colspan="3">a. Logged pilot time or provided flight instruction (IP) (make and model)</td><td colspan="4">b. Passed an Instrument Proficiency Check (Pilot or CFI) - (make and model)</td></tr><tr><td colspan="3"></td><td colspan="3"></td><td colspan="4"></td></tr><tr><td rowspan="2">□</td><td rowspan="2">C. Graduate of an approved Course</td><td>1.Training Agency or Training Center:</td><td colspan="4">1a. Name</td><td colspan="2">1b. Location (City and State)</td><td>1c. Certification Number</td><td>1d. Part 142</td></tr><tr><td></td><td colspan="4"></td><td colspan="2"></td><td></td><td>□ Yes□ No</td></tr></table> GACA-AVSES-OPS-F001 Rev: 3, Date: 24 Apr 25 Page 1 of 6 GACA المملكه العربيه للطرين العدن General Authority of Civil Aviation [Non-Text] PILOT CERTIFICATE AND/OR RATING APPLICATION <table><tr><td></td><td></td><td colspan="15">2. Curriculum From Which Graduated (Level, Category, and Class and/or Type Rating)</td><td colspan="2">3. Date</td></tr><tr><td rowspan="3"></td><td rowspan="3">D. Holder of Foreign License</td><td colspan="8">1. Country that Issued the Foreign Pilot License</td><td colspan="4">2. Grade of Foreign Pilot License</td><td colspan="5">3. Foreign Pilot License Number</td></tr><tr><td colspan="8">4. Ratings Held on Foreign Pilot License (GACA equivalent only – e.g. ASEL, AMEL, Type Rating, etc.)</td><td colspan="4"></td><td colspan="5"></td></tr><tr><td colspan="8">1. Name of Air Carrier</td><td colspan="4">2. Date Training Began</td><td colspan="4">3. Accomplished Training Program</td></tr><tr><td rowspan="2" colspan="14">III. RECORD OF PILOT TIME (Do not write in the shaded areas)</td><td colspan="2"></td><td colspan="2">Initial</td><td colspan="2">Upgrade</td></tr><tr><td colspan="2">Transition</td><td colspan="2">Recurrent</td></tr><tr><td></td><td>Total</td><td>Instruction Received</td><td>Solo</td><td>PIC and SIC</td><td>Cross Country Instruction Received</td><td>Cross Country Solo</td><td>Cross Country PIC/SIC</td><td>Instrument</td><td>Night Instruction Received</td><td>Night Take-Off / Landing</td><td>Night PIC/SIC</td><td>Night Take-Off/Landing PIC/SIC</td><td colspan="2">Class Totals</td><td>Flights</td><td>Aero- Tows</td><td>Ground Launches</td><td>Powered Launches</td></tr><tr><td rowspan="2">Airplanes</td><td rowspan="2"></td><td rowspan="2"></td><td></td><td></td><td rowspan="2"></td><td></td><td></td><td rowspan="2"></td><td rowspan="2"></td><td></td><td></td><td></td><td rowspan="2"></td><td rowspan="2"></td><td rowspan="2"></td><td rowspan="2"></td><td rowspan="2"></td><td rowspan="2" colspan="2"></td></tr><tr><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Rotorcraft</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td>2.</td></tr><tr><td rowspan="2">Powered Lift</td><td rowspan="2"></td><td rowspan="2"></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><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><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td rowspan="2">Glider</td><td rowspan="2"></td><td rowspan="2"></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td>1</td><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><td></td><td></td><td></td><td>1</td><td></td><td></td><td></td><td></td><td></td><td></td></tr></table> <table><tr><td>FFS</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>FTD</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr></table> IV. Have you previously failed the practical test for the certificate or rating for which you are applying? □ Yes □ No If Yes, Enter date of last disapproval 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 may 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>Signature of Applicant</td><td>Date</td></tr><tr><td></td><td></td></tr></table> GACA-AVSES-OPS-F001 Rev: 3, Date: 24 Apr 25 Page 2 of 6 GACA الطبيه العامه للطيران المدني General Authority of Civil Aviation PILOT CERTIFICATE AND/OR RATING APPLICATION <table><tr><td colspan="10">INSTRUCTOR ACTION</td></tr><tr><td colspan="2">☐ Flight Review</td><td colspan="2">☐ Instrument Proficiency Check</td><td colspan="6">☐ Recommendation I have personally instructed the applicant and consider this person ready to take the test.</td></tr><tr><td>Date</td><td colspan="5">Certified Flight Instructor's Signature (Print Name and Sign)</td><td colspan="2">Certificate Number</td><td colspan="2">Certificate Expires</td></tr><tr><td></td><td colspan="5"></td><td colspan="2"></td><td colspan="2"></td></tr><tr><td colspan="10">AIR AGENCY'S RECOMMENDATION</td></tr><tr><td colspan="10">The applicant has successfully completed our xxx course and is recommended for certificate or rating.</td></tr><tr><td>Date</td><td colspan="5">Agency Name and Number</td><td colspan="4">Official Signature</td></tr><tr><td></td><td colspan="5"></td><td colspan="4"></td></tr><tr><td colspan="10">DESIGNATED EXAMINER REPORT</td></tr><tr><td>☐</td><td colspan="9">Student Pilot Certificate Issued (Copy attached)</td></tr><tr><td>☐</td><td colspan="9">I have personally reviewed this applicant's pilot logbook and/or training record, and I certify that the individual meets the applicable requirements of GACAR Part 61 for the certificate or rating sought.</td></tr><tr><td>☐</td><td colspan="9">I have personally reviewed this applicant's graduation certificate, and found it to be appropriate and in order, and have returned the certificate.</td></tr><tr><td>☐</td><td colspan="9">I have personally tested and/or verified this applicant in accordance with pertinent procedures and standards with the result indicated below.</td></tr><tr><td colspan="5">☐ Approved – Temporary Certificate Issued (Original Attached)</td><td colspan="5">☐ Disapproved – Disapproval Notice Issued (Original Attached)</td></tr><tr><td colspan="5">Location of Test (Name of Facility or Aerodrome, City, Province)</td><td colspan="5">Duration of Test</td></tr><tr><td colspan="5"></td><td>Ground / Oral</td><td colspan="2">FFS / FTD</td><td colspan="2">Flight</td></tr><tr><td colspan="5"></td><td></td><td colspan="2"></td><td colspan="2"></td></tr><tr><td colspan="4">Certificate or Rating Being Applied For (Grade, Category, Class and/or Type Rating)</td><td colspan="2">Type(s) of Aircraft Used</td><td colspan="4">Registration Marks</td></tr><tr><td colspan="4"></td><td colspan="2"></td><td colspan="4"></td></tr><tr><td>Date</td><td colspan="3">Examiner's Signature (Print Name & Sign)</td><td colspan="2">Certificate Number</td><td colspan="3">Designation Number</td><td>Designation Expires</td></tr><tr><td></td><td colspan="3"></td><td colspan="2"></td><td colspan="3"></td><td></td></tr><tr><td colspan="10">EVALUATOR'S RECORD (Use for All ATP Certificate(S) And/or Type Rating(s))</td></tr><tr><td></td><td>Inspector</td><td>Examiner</td><td colspan="5">Signature and Certificate Number</td><td colspan="2">Date</td></tr><tr><td>Oral</td><td>☐</td><td>☐</td><td colspan="5"></td><td colspan="2"></td></tr><tr><td>Approved FFS/FTD Check</td><td>☐</td><td>☐</td><td colspan="5"></td><td colspan="2"></td></tr><tr><td>Aircraft Flight Check</td><td>☐</td><td>☐</td><td colspan="5"></td><td colspan="2"></td></tr><tr><td colspan="10">AVIATION SAFETY INSPECTOR</td></tr><tr><td colspan="10">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. (The approved box need only checked if the Inspector is the one that issued the temporary airman certificate)</td></tr><tr><td colspan="5">□ Approved – Temporary Certificate Issued (Original Attached)</td><td colspan="5">□ Disapproved – Disapproval Notice Issued (Original Attached)</td></tr><tr><td colspan="5">Location of Test (Name of Facility or Aerodrome, City, Province)</td><td colspan="5">Duration of Practical Test</td></tr><tr><td colspan="5"></td><td>Ground / Oral</td><td colspan="2">FFS / FTD</td><td colspan="2">Flight</td></tr><tr><td colspan="5"></td><td></td><td colspan="2"></td><td colspan="2"></td></tr><tr><td colspan="4">Certificate or Rating Being Applied For (Grade, Category, Class and/or Type Rating)</td><td colspan="2">Type(s) of Aircraft Used</td><td colspan="4">Registration Marks</td></tr><tr><td colspan="4"></td><td colspan="2"></td><td colspan="4"></td></tr></table> GACA-AVSES-OPS-F001 Rev: 3, Date: 24 Apr 25 Page 3 of 6 GACA المجله للطيران المدني General Authority of Civil Aviation [Non-Text] PILOT CERTIFICATE AND/OR RATING APPLICATION <table><tr><td colspan="4">CERTIFICATION ACTIVITIES</td></tr><tr><td colspan="2">☐ Examiner's Recommendation Provided/Reviewed</td><td>☐ Ground Instructor Certificate Issued</td><td>☐ Flight Instructor Certificate Issued</td></tr><tr><td>☐ Accepted</td><td>☐ Rejected</td><td>☐ Basic</td><td>☐ Initial ☐ Renewal ☐ Reinstatement</td></tr><tr><td colspan="2">☐ Student Pilot Certificate Issued</td><td>☐ Advanced</td><td>☐ Instructor Renewal Based On</td></tr><tr><td colspan="2">☐ Reissue or exchange of pilot, certificate</td><td rowspan="3">☐ Instrument</td><td>☐ Activity ☐ Training Course</td></tr><tr><td colspan="2">☐ Change of name, nationality, or date of birth</td><td rowspan="2">☐ Test ☐ Duties and Responsibilities</td></tr><tr><td colspan="2">☐ SIC Type Rating issued under GACAR § 61.19</td></tr><tr><td colspan="2">Training Course (FIRC) Name</td><td colspan="2">Graduation Certificate Number</td></tr><tr><td>Date</td><td colspan="2">Inspector's Signature (Print Name & Sign)</td><td>Inspector Credential No. GACA Department</td></tr><tr><td></td><td colspan="2"></td><td></td></tr><tr><td colspan="2">Attachments</td><td>Airman's Identification (ID) (driver's license or passport recommended)</td><td>Applicant Information (required if printed on 2 pages)</td></tr><tr><td colspan="2">□ Student Pilot Certificate (Copy)</td><td></td><td></td></tr><tr><td colspan="2">□ ATP CTP Graduation Certificate</td><td>Form of ID</td><td>Name</td></tr><tr><td colspan="2">□ Knowledge Test Report</td><td></td><td></td></tr><tr><td colspan="2">□ Temporary Airman Certificate</td><td>ID Number</td><td>Date of Birth</td></tr><tr><td colspan="2">□ Notice of Disapproval</td><td></td><td></td></tr><tr><td rowspan="3" colspan="2">□ Superseded Airman Certificate</td><td>Expiration Date (must be valid)</td><td>Certificate Number</td></tr><tr><td>Telephone Number</td><td>E-Mail Address</td></tr><tr><td>REMARKS from Inspector or Examiner</td><td></td></tr></table> GACA-AVSES-OPS-F001 Rev: 3, Date: 24 Apr 25 Page 4 of 6 GACA المملكه العربيه السعوديه General Authority of Civil Aviation [Non-Text] PILOT CERTIFICATE AND/OR RATING APPLICATION INSTRUCTIONS FOR COMPLETING THE APPLICATION I. APPLICATION INFORMATION. Mark "X" in all appropriate blocks(s). Note: Please enter all dates in eight digits as DD/MM/YYYY. Use numeric characters, (e.g. 01/01/2014). Block A. Name. Enter full legal name (Last, First, Middle). If your full legal name is more than 50 characters, use no more than one middle name for record purposes. Do not change the name on subsequent applications unless it is done in accordance with GACAR Part 61.33. If you do not have a middle name, enter “NMN.” If you have a middle initial only, indicate “Initial only.” Indicate if you are a Jr., II, or III. Block B1. ID/IQAMA Number. Enter either your 10-digit National Identification number or Residential Permit No., “None” if you are not a Saudi citizen and don't have Resident Permit (Iqama). Block B2. Passport Number. Enter your Passport Number with any Letters in Uppercase character. Block C. Date of Birth. Enter your date of birth in the following format: DD/MM/YYYY. Check for accuracy. Verify that DOB is the same as it is on the medical certificate. Block D. Place of Birth. Enter the name of the city and country where you were born. Block E1. Residential Address. Enter your complete residential address. This must include street number, city, state, and postal code. If the applicant has a foreign address, the country must be stated. If a residential address does not exist, a map or written directions to the applicant's physical residence must be attached to the application. Verify that the numbers are not transposed. Block E2. Mailing Address. If employed by a Company enter your Company mailing address or if not employed by a company enter your personal address, if different than block E1. This may be a residence, post office box, rural route, flight school address, personal mailbox (PMB), commercial address, or other mail drop location, as applicable. The address provided in block E2, if any, will be printed on the permanent airman certificate. If you want your airman certificate mailed to an address other than provided in blocks E1 or E2, you will need to provide instructions on a separate attachment or in the remarks section of the form. Block F. Citizenship. Mark SAUDI if you are a SAUDI Citizen. If you are not a SAUDI citizen mark “Other” and enter the country where you are a legal citizen. To claim Dual Citizenship the applicant must present appropriate documentation of citizenship for each country. Block G. ELP Level & Expiry Date Enter your ELP level as a number and the Expiry date (if applicable) in the following format: DD/MM/YYYY. Block H. Height. Enter your height in centimeter. Block I. Weight. Enter your weight in kilograms. No fractions, use whole kilograms only. Block J. Hair Color. Spell out the color of your hair. Choose from the following: bald, black, blond, brown, gray, red or white. If you wear a wig or toupee, enter the color of your hair under the wig or toupee. Block K. Eye Color. Spell out the color of your eyes. Choose from the following: black, blue, brown, gray, green, or hazel. Block L. Sex. Mark either Male or Female as appropriate. Block M. Do You Hold or Have You Ever Held a GACA Pilot Certificate? Mark yes or no. (NOTE: A student pilot certificate is a pilot certificate.) If. Yes, complete Blocks M1, M2, and M3. Block M1. Grade of Certificate. Enter the grade of the GACA pilot certificate you hold (i.e., Student, Sport, Private, Commercial, or ATP). DO NOT enter the flight instructor's certificate information. Block M2. Certificate Number. Enter your current GACA certificate number as it appears on the pilot certificate. Block M3. Date Issued. Enter the date your pilot certificate was last issued. Block N. Do You Hold a Medical Certificate? Mark applicable boxes. If yes, complete blocks N1, N2, and N3. Block N1. Class of Medical Certificate. Enter the class as shown on the medical certificate, (i.e., Class 1 or Class 2). Block N2. Name of Medical Examiner. Enter the medical examiner's name as shown on your medical certificate. GACA-AVSES-OPS-F001 Rev: 3, Date: 24 Apr 25 Page 5 of 6 GACA المملكه العربيه السعوديه General Authority of Civil Aviation PILOT CERTIFICATE AND/OR RATING APPLICATION Block N3. Date Issued. Enter the date your medical certificate was issued. Block O. Narcotics Drugs. Mark appropriate block. Only mark “Yes” if you have actually been convicted. If you have been charged with a violation which has not been adjudicated, mark “No.” Do not include alcohol offenses involving a motor vehicle mode of transportation. Block N2. Name of Medical Examiner. Enter the medical examiner's name as shown on your medical certificate. Block O1. Date of Final Conviction. If block "N" was marked "Yes" provide the date of final conviction. II. CERTIFICATE OR RATING APPLIED FOR ON BASIS OF Block A. Completion of Required Test. 1. Aircraft to be used. (If flight test required) – Enter the make and model of each aircraft used or represented. If a flight simulation training device (FSTD) is used, indicate Level of Device(s). 2. Total time in this aircraft and/or approved full flight simulator (FFS) or flight training device (FTD) (Hrs.) – (2a) Enter the total Flight Time (2b) Enter Pilot-In-Command (PIC) Flight Time. Block B. Military Competence or Experience. Enter your branch of service, date rated as a military pilot, and your rank or grade. In block 4a and 4b, enter the make and model of each military aircraft used to qualify (as appropriate). Block C. Graduate of an Approved Course. 1. Name, Location, Certification Number of Training Agency/Center, as shown on the graduation certificate. Indicate if this was GACAR part 142 training 2. Curriculum from Which Graduated. Enter name of curriculum and level, category, and/or type rating, as applicable. 3. Date. Date of graduation from indicated course. Note: Approved course graduate must also complete block A “Completion of Test or Activity,” if the course is not part of an Air Agency or GACAR part 142 Training Center. Block D. Holder of Foreign License. 1. Country that Issued the Foreign Pilot License. 2. Grade Of Foreign Pilot License (i.e. private, commercial, etc.). 3. Number. Number which appears on the foreign license. 4. Ratings. Enter the GACA equivalent only ratings that appear on the foreign license. Indicate the ratings as they will appear on the GACA Certificate (i.e. ASEL, AMEL, ROTORCRAFT HELICOPTER, CE-500, etc.). Block E. Completion of Air Carrier's Training Program. III. RECORD OF PILOT TIME. At a minimum, the applicant should complete the blocks applicable to the certificate or rating sought; however, it is recommended that all pilot time be entered. If decimal points are utilized, ensure that they are legible. Time entered in the “Class Totals” block should reflect time in aircraft class for the certificate or rating sought with this application. The time entered for an FFS, FTD, and/or ATD may be credited towards the total time in the category, class, and instrument time as permitted by the regulations. Add any Flight Engineer time used for ATP in the remarks section. IV. HAVE YOU FAILED A PRACTICAL TEST FOR THIS CERTIFICATE OR RATING? Mark "Yes" or "No" as appropriate. V. APPLICANT'S CERTIFICATION. A. Signature. Sign your name. B. Date. The date you signed the application. GACA-AVSES-OPS-F001 Rev: 3, Date: 24 Apr 25 Page 6 of 6