GOVERNMENT OF INDIA CIVIL AVIATION DEPARTMENT File No. APPLICATION FOR THE ISSUE/ CONVERSION OF ATPL(AEROPLANE} Name (as in 10" certicate) Father's Name Mother's Name Affix self attested recent 2 _| Date of birth & Age photograph of size (as in 40” cortieate) 3x4om 3._| Place of birth {also enclose atleast 5 photographs with form) “4. Country of birth 5. Nationality 6. | Correspondence address 7._| Permanent address (signature of cansisate) 8, Educational Qualification: Examination] Name of Boardi university Year | Subjects offeredivte rane iatiean | Remarks (y | Class Xor equivalent {iy | Class xi! or equivalent (iii) | Any other TE 1 sab Fa recap ed Board Unveriy T sa ave Pye and Was: For reaigiin and quale pase eee Pom Asacatn of aan UNOS 9. Knowledge: (Computer Number - Paper Passed in Session| Roll No. | Date of Result Valid upto _| Reman ‘Air Regulation 2) | (oot aque for Rol valid naan CPL) b) | Air Navigation ©) | Aviation Meteorology d) | Radio Aids and Instrument ‘ATPL Composite €) | (atieu or), a) it applied or Sonversion) Technical General f) | {not required, if applied for conversion snd foreign ATPL ison ul Technical Specific 9) | (rotraqared H apple for conversion nd foreign ATPL Ison mat) Ale Nami (li) Alc Name. Technical Performance 4 | Grot required, i pated or conversion eign ATPL ie on mt) () Alc Name. (li) Ave Name.. [Signal reception test esswnm | tetrequres, spl for converson and Passed Yes! No foreign ATPL Is on multi)70, [RTR and FRTOL details Number | Date ofissue | Valid upto | Whether applied | Remarks ] Details of RTR(A)RTR(P) for FRTOL P FRTOL License Yes/No 11, Details of Class-1 indian Medical Medical Centre Date of medical Valid upto Remar] Clase medicals val Tor one-year I ago Ts alow 40 yr and valid or 6 mans Wago fe 0 and above. 12. Flying experience: a) Total flying details til date: from To “Hiefiown [_SINGLE ENGINE AIRCRFAT 'MULTIENGINE AIRCRAFT INSTRUMENT THE DAY NIGHT DAY GET onalrat |, we | Pt ee | Pi Sin ra Dual | soo | ovat | so | ur | fe | by | me | ur | oe | ey] me | rom [Simi | cma |simunorty EC TOTAL Tole: wile PT Urs exporionce separaloly and dont ince i Co-pol column, feubmit PTUIS) fog book awa] Total lying experience til THE DATE OF SUBMISSION OF PAERS IN DGCA (fil up in the following table from table a) above: Requirement Hrs Req. | Actual Renan Total flying experience details i) | Tota ying time (nts 50% ofall cpl a we counted) (| (coi (13))— (50% of col6)+(10)) 1800 ip] Total a8 PIC (nie PY US fre are comma SO% coo (1) | cot (2) +(4)+(8)+(12)) + {50% of Col (7)+(11)} “Total Night fying experience (n is 50% of ml contol gn Wa we canted 4100 {€a18) +@ye19)+(11y9(12p + (80% of Col (10) (i) | Total Instrument Time {col (14)+(15)+(16)} 400 {not more than 50 hrs shall be counted from col 16) (allach sortie wise statement ) Xeountry flying time (v)_| Total Xcountry by day and night (atach soe we stoner) 7000 (vi) | Total PIC X:country by day and nla (tec sore wise sttomoa 200 (vil) [Total PIC X-country flying time by Night (atach sone ws statement) | _80 ) Fving in proceding one Year FROM THE DATE OF SUBMISION OF PAERS NDGCA( FROM 10 ) Alsfown [SINGLE ENGHE ARCRFAT MULTTENGNE ARCRAPT iNSTRUMENT TE oat nT oar oT nate oa | som | om | som | or] Sy | eh pre | or] Se | ee] me | tom | SRE | aca [oh CO TOTAL ‘Total flying experience in preceding one year: (fil up in the fallowing table from table b) above) Requirement irs Req. | Actual Fara Total fying time jn tie SOW fa capo sao cad) 150 (col (13)} {50% of eal6)¥(10) «)Fyingin prcading 6 months FROM THE DATE OF SUBMISSION OF PAERS IN DGCA| FROM 10 } [ Ae flown [SINGLE ENGNE ARCRFAT ULTTENGINE AIRCRAFT inStUMENT TE ° oaY NIGHT oa NGA THAR Tans Boat | oe | om | soe | ut | cy | my) Pe | oT] Se | ey] Pe | Tom | S| Aen! fierh Tete ee eae eo oe yao) TOTAL Total flying experience in preceding six months year. (up in he folowing table rom table (c) above) Requirement Hrs Req. | Actual Raman Total flying time mins 50% of mull comlol ws are counted)13. Skill in preceding six months from date of application in DGCA, as required vide section-M 'a)__| Requirement ‘AleName | duration | Date of test_| Valld upto [fick CPLR vald on mati] Pera ()_| general flying test by day (GFT aoeragsied CPL wit vals) CPL is valid ~ Yes (iy_| general flying test by night {Get ne requied CCPL wih i al) Gi) | IR Test TRis valid - Yes GCA exam on that arr ype For additional aircraft ratings (A/c Name... The sl Tats iturant ratng Wat shal be aubmtied th OGCA approved performa, Each Tat ropa shal be uly egned by he UGCA approve 8 counter signed by tho arodrome authorities and shall be submited in original. (OGCA approved perormas are avaiable on DGCA website under tab- forms). Althe above tests Le 133) (Bl) shall be on the same aera ype. Al the fying teste shall have been conducted only ..attach Alc specific result & give details in 9 above) the date of passing of b) _| Requirement Duration Date of Test Valid upto Tee (| general flying test by day (i_| general flying test by night Gi) [IR Test 15. | Were you been involved in aircraft accident! incident in preceding 5 years | Yes/No yes, give details thereof; with the disciplinary action taken, if any: [ 16. [Do you hold an Indian CPL — Yes / No (ifyes, give following details) T ‘CPL Licence Number | Issue date__| Valid upto | PIC endorsements |Co-pilol endorsements 17,_|_Do you hold an Indian instrument Rating on CPL — Yes / No (if yes, give following details) IR Number, Issue date | last/Rtestdate | Last IR on Aircraft/sim Valid upto: acral Level 0’ Simulator 18. Fee Details: Tater IR Tats vale Tor one year Wom The Gave of test and Tt shal be endorsed on Te Wesrament rang sued on OPL. IR Test shall be on DD Number and Date | Place of issue & Bank Name | Amount If fees Is to be debited in the Advance Deposit Account of the operator, please fill up following= Name of Operator ‘Signature of authorized Name Seal ‘Fa shal padi To Berard Dah a on ay atenaleed bank Tor Pay and Rezats OF, Deer Corer Now Dat payable a Det Ref ule 48 ree amount e500 fr save of ach cane and adaonal 500 fr sacha 19. for defense personnel only: ran/nsunent rating) I Aa, My Cl Ta, years has been obtained from the concerned Hars. ‘Condition Complied ‘Whether the applicant Is/ was In the service of Defense Forces of India. Yes/No If serving, No Objection Certificate obtained from the concerned Hgrs. Yes/No Ifserving, indicate whether accidentiincident free cer Yes/No iv) | ifnot serving, indicate the Force. and date of release... (attach copy of release ceifiste)20. If application is for conversion of foreign ATPL, please give following details; also:~ a) | Details of foreign license Country of issue ii) Name & Number of license ALTP- iii) Date of issue of license ity of v)_ Aircraft ratings (PIC/Co-pilot) vi) Instrument Rating ®) | Details of foreign medical i) Class & Date of foreign medical ii) Validity of foreign medical ©) | Have you enclosed the verification of foreign contracting state's regulatory authority wage and medical from the Yes/No 4) | Name, address, website & e-mail ID of the contracting state's flying training institute from where you did training. @) | Details of passport & travel for fiying training (enclose copy of all he pages) Full Name on Passport: Passport Number: iil) place of Issue: ) valid upto: 21. Any other information: Declaration by the Applicant | declare that in terms of provisions of Rule 39A of the Aircraft Rules, 1937, | have not suppressed or given any wrong information herein above for the purpose of obtaining the licence/ rating applied for here. | understand that | am liable for appropriate action, if any information given by me is found to be wrong even at a later date. Place: Date Signature of the applicant21, Please tick the list of enclosures submitted : ‘SI_| List of the documents to be submited with application form ‘Submitted For knowledge have you submitted: Yes No T._| Passed result of Air Regulation (not required for holder of valid Indian CPL ana 2._| Passed result of Air Navigation 3._| Passed result of Aviation Metearalog 4._| Passed result of Radio Aids and Instrument 5. Passed result of ATPL Composite tin leu of Nav Not @ Radio side Wapplied for conversion) 6._| Passed result of Technical General (not required, if applied for conversion) Passed result of Technical Spectfic 7. | {om contracting stale, if apted for Conversion; not required i mull ale is endorsed on frsign ATPL} or asuedin india not reid already have vate mul endorsement on Indian GPU) Passed result of Technical Performance 8. | womeoncin at, W aprox crv net wg mula ene on fon ATPL) 9, | Passed result of signal reception test @ 6/8 w.p.m. {trom contraction stale, applied for conversion ot require it Raving valid indian CPL For flying experience have you submitted: 10._| Duly certified log books and separate log book of Pt UIS T1._| CA39 duly certified by the competent authority Tor total flying period 12._| CA39 duly certified by the competent authority for preceding one year 13._| CA39 duly certified by the competent authority for preceding six months 14._| Sorlie wise statement of total X-country flying 15.__| Sorlie wise statement of total PIC X-country flying 16._| Sorlie wise statement of total PIC X-country flying by night 17._| Sorlie wise statement of at least 100 hrs instrument flying 18, | Repor of General Flying Test by Day (in preceding 6 months) et reqiad r tle etvtatan CPL ssa) 19. | (ehuied or raf duainsan er? aay" Preceang © months) 20, | Felon onl ant dan bet on at Zi, Accident inedent record, fan General tems 29, | RTRIA) License or Resuk of RTR(A) evam (f passed receniiy) (Sut TRU) Hares ios fore ng of ih crew Yeaee ans alo ve a copy oiense) 23__ If you hold any other DGCA license please give a copy 24._| 10" certificate in original and an attested copy 25._| Verification of 10 certificate from the concerned boardl university 26._| 12” Cerificate in original and an attested copy 27.__| Verification of 12” certificate from the concerned board university 28._| Valid Calss-I medical assessment or CA-35 form in original and a Cop) 29._| Foreign license with copy (if applied for conversion '30._| Valid foreign medical assessment with Copy (if applied for conversion) 31, | Verification of foreign licensef raling and medical from stale (if applied for conversion 32._| Full copy of the passport (if applied for conversion] '33,_| Five photographs 34, | Have you submitted fee as per rule 48 For Defense personnel on '35._| If serving defense personal, have you submitted NOC from the concerned Har. 136, | If serving defense personal, have you submitted accident/incident free certificate for the preceding 5 years from concerned Har. [37__[ifnon-serving defense personal, have you submilied the release certificate, |INSTRUCTIONS TO THE APPLICANTS This application, duly filled may be submitted personally OR through an authorized person OR by registered post to Director Training & Licensing, Directorate General of Civil Aviation, Technical Centre, Opp. Safdarjang Airport, Aurbindo Marg, New Delhi 110003, 2. The date of application is the date at which the application is received in DGCA. Therefore, applicant shall ensure his application reaches in time at DGCA. 3. All the calculations of the validity, total flying, flying in preceding 12 months/ 6 months is based on the date of application in DGCA and applicant shall possess all the requisite documents including medical, DGCA written exam results, RTR(A) on the date of submission of papers in DGCA, else application would be summarily rejected. 4, In case of foreign national, enclose nationality certificate OR attested copy of passport, 5. fill up separate CA-39 for total flying , flying in preceding one year and preceding 6 month (total 3 CA-39). A sample CA-39 performa is with this form. 6. Log book shall be maintained as per rule 67 and there shall be no cuttings. The entries of the skill tests/X- country tests/ IR tests shall be duly certified in the log book by the examiner who conducted the check. The number of landings carried out during the tests shall be clearly mentioned in the log book. 7. In case of application for conversion of foreign license, applicants are required to submit preceding six months record of flying by giving the copy of relevant portion of the log book. 8. All the skill tests shall be conducted only after the candidate passes the written examination for that type of aircraft 9, The photograph shall be identical, recent, coloured, size 3omx 4m showing frontal view of full face and having name printed on them. The name shall be the same as in 10” certificate. 10, If, any person has changed his name than what appears on his 10” certificate, he shall submit all the relevant certificates and documents required by law in support of change in name. 14, Remarks column is for office use only,CA-39 For a period FROM To Name of Licence Holder. Licence Class :. ... License Number ... .......... Valid upto. Aircrafts flown. [ SINGLE ENGINE AIRCRFAT | MULTI ENGINE AIRCRAFT T [INSTRUMENT TIME Wate HY GET ORY HT GHAR Tr ver [Tout | som [ou | soe [or [is |e |e [or [se [Bh] we | vm | ny [ann [amy OTATO To) o®] oO] Mm) @] ® | om] mn] ma] oy [oH] os | 16 ToTAL aie wiite PT Us experiance separately and do not neds Co-pot cata This is to certify that | have examined the logbooks of Mr. .. and the above is a true summary. Countersigned Name. Designation Company name Seal Date... Signature of License Holder Date. Note: fill up separate CA-39 for total flying , flying in preceding one year and preceding 6 month (total 3 CA-39)