Republic of Iraq

Civil Aviation Authority

Flight Safety Department

APPLICATION FOR LICENCE, RATING, AUTHORISATION OR CERTIFICATE

☐ Issue ☐ License Equation ☐ Re-Issue ☐ Renewal ☐ Validation
I. Application information

☐ Private Pilot ☐ Student Pilot Authorization ☐ Instrument

☐ Commercial Pilot ☐ Flight Instructor Authorisation ☐ Aerodrome control
☐ Multi-Crew Pilot ☐ Ground Instructor Authorisation ☐ Approach control procedural
☐ Airline Pilot Transport ☐ Instructor Authorisation ☐ Category A
☐ Air Traffic Controller ☐ Check Airman Authorisation ☐ Category B1
☐ Flight Dispatcher ☐ Examiner Designation ☐ Category B2
☐ Aircraft Maintenance ☐ Category: ☐ Category C
Engineer
☐ Engine:
☐ Cabin Crew Certificate ☐ Class:
☐ Other (specify):
☐ Type Rating:

A. Full Name: B. Date of birth ( / / )

C. Address: D. Nationality:
ijj E. Email : F. Telephone:
E-Mail (CAA or ATO):
G. Type of licence held H. Number I. Date issued

J. Class of Medical Assessment K. Date issued

II. Experience
Flight instruction: PIC Co-Pilot: PIC “cross country” Instruments: Night flight: Flight Sim : Total time:

Other Categories:
Month: Year :
III. Declaration
I certify that the statements made by me on this application are A. Signature: B. Date:
True:
IV. Attachments (To be certified by the administrative support officer)

☐ Knowledge test report ☐ Training certificate ☐ Medical certificate

☐ Skill test report ☐ Proficiency check report ☐ Language proficiency report
☐ Logbook ☐ License ☐ Identification document
☐ Two passport-size photographs ☐ Fee (paid / billed) ☐ Work Sheet
V. ICAA Use Only
☐ Satisfactory ☐ Unsatisfactory

Remarks:………………………………………………………………………………………………………………
ASI No: ASI Signature: Date:

FSD-PEL-FORM 003 APRIL, 2019

This form is available at (www.icaa.gov.iq), for further information please contacts ((Safety.manager@icaa.gov.iq).