Common use of Application Form Clause in Contracts

Application Form. (Available from the Aviation Authorities) PART-FCL LICENCE APPLICATION FORM It is required that this form be filled and signed by the candidate The first part of this form needs to be filled in with the details of the FAA airman certificate and its endorsements. These items will be verified in consultation with FAA. The second part concerns the application for the EU licence itself. PART 1: FAA Airman status ITEM ICAO ANNEX 1 DESCRIPTION In accordance with the Chicago Convention on International Civil Aviation, Article 29,c); 32,a); 40; and Annex 1 to the Convention, para 1.2.1. 1 (i) State of licence issue USA 2 (ii) Category/Class of FAA certificate AEROPLANES: □ PPL □ CPL □ ATPL 3 Licence issue date Dd/mm/yyyy 4 (iv) Full name (Last and first names) LAST NAME, First name 5 (iv a) Date of birth (dd/mm/yyyy), or National ID number Dd/mm/yyyy …………………………………………. [PII not provided by FAA in airman verification process. The applicant must provide.] 6 (xiv) Other detail (for example Place of birth) Optional [PII not provided by FAA in airman verification process. The applicant must provide.] 7 (v) Address: - Permanent address: - Postal address: [PII not provided by FAA in airman verification process. The applicant must provide.] 8 Contact details: - Email: - Phone number: Personal contact details [PII not provided by FAA in airman verification process. The applicant must provide.] 9 (vi) Nationality Dutch [PII not provided by FAA in airman verification process. The applicant must provide.] 10 (viii) Issuing authority (conditions under which the licence was issued, where necessary) FAA 11 (xii) Valid and non-expired ratings/privileges and certificates held (Only Class or Instrument ratings) Ratings and certificates Issue date (dd/mm/YYYY) SEL xx/xx/xxxx 12.. Expired ratings: N/A 13 (xiii) Remarks, i.e., special endorsements relating to limitations, restrictions and endorsements for privileges (e.g.: language proficiency level and validity (English, others)) Special endorsements: Last Flight Review in English (for language request) Date (dd/mm/yyyy): 14. Details on completion of theoretical-knowledge or flight instruction, theoretical-knowledge examination or skill test in other Member States, if applicable : N/A 15 Past or pending enforcement action* Yes 🞏 No 🞏 (If yes, please give details on a separate page.) 16 Is the licence in point 2 a validation issued by the FAA on the basis of a licence issued by another Contracting State to the Chicago Convention.** Yes 🞏 No 🞏 (Please add details hereunder) 17 Initial PART-MED medical certificate: Date of issue: xx/xx/xxxx Date of examination: xx/xx/xxxx Class: * Item 15 specify if there is a current investigation into the medical certificate and licence, or suspension or revocation thereof. ** Item 16: e.g. has it been rendered valid according 1.2.1 of Annex 1 of the Chicago Convention?

Application Form. (Available from the Aviation Authorities) PART-FCL LICENCE APPLICATION FORM It is required that this form be filled and signed by the candidate The first part of this form needs to be filled in with the details of the FAA airman certificate and its endorsements. These items will be verified in consultation with FAA. The second part concerns the application for the EU licence itself. PART 1: FAA Airman status ITEM ICAO ANNEX 1 DESCRIPTION In accordance with the Chicago Convention on International Civil Aviation, Article 29,c); 32,a); 40; and Annex 1 to the Convention, para 1.2.1. 1 (i) State of licence issue USA 2 (ii) Category/Class of FAA certificate AEROPLANES: □  PPL □  CPL □  ATPL 3 Licence issue date Dd/mm/yyyy 4 (iv) Full name (Last and first names) LAST NAME, First name 5 (iv a) Date of birth (dd/mm/yyyy), or National ID number Dd/mm/yyyy …………………………………………. [PII not provided by FAA in airman verification process. The applicant must provide.] 6 (xiv) Other detail (for example Place of birth) Optional [PII not provided by FAA in airman verification process. The applicant must provide.] 7 (v) Address: - Permanent address: - Postal address: [PII not provided by FAA in airman verification process. The applicant must provide.] 8 Contact details: - Email: - Phone number: Personal contact details [PII not provided by FAA in airman verification process. The applicant must provide.] 9 (vi) Nationality Dutch [PII not provided by FAA in airman verification process. The applicant must provide.] 10 (viii) Issuing authority (conditions under which the licence was issued, where necessary) FAA 11 (xii) Valid and non-expired ratings/privileges and certificates held (Only Class or Instrument ratings) Ratings and certificates Issue date (dd/mm/YYYY) SEL xx/xx/xxxx 12.. Expired ratings: N/A 13 (xiii) Remarks, i.e., special endorsements relating to limitations, restrictions and endorsements for privileges (e.g.: language proficiency level and validity (English, others)) Special endorsements: Last Flight Review in English (for language request) Date (dd/mm/yyyy): 14. Details on completion of theoretical-knowledge or flight instruction, theoretical-knowledge examination or skill test in other Member States, if applicable : N/A 15 Past or pending enforcement action* Yes 🞏 No � � (If yes, please give details on a separate page.) 16 Is the licence in point 2 a validation issued by the FAA on the basis of a licence issued by another Contracting State to the Chicago Convention.** Yes  🞏 No 🞏 (Please add details hereunder) 17 Initial PART-MED medical certificate: Date of issue: xx/xx/xxxx Date of examination: xx/xx/xxxx Class: * Item 15 specify if there is a current investigation into the medical certificate and licence, or suspension or revocation thereof. ** Item 16: e.g. has it been rendered valid according 1.2.1 of Annex 1 of the Chicago Convention?

Application Form. (Available from the Aviation Authorities) PART-FCL LICENCE APPLICATION FORM It is required that this form be filled and signed by the candidate The first part of this form needs to be filled in with the details of the FAA airman certificate and its endorsements. These items will be verified in consultation with FAA. The second part concerns the application for the EU licence itself. PART 1: FAA Airman status ITEM ICAO ANNEX 1 DESCRIPTION In accordance with the Chicago Convention on International Civil Aviation, Article 29,c); 32,a); 40; and Annex 1 to the Convention, para 1.2.1. 1 (i) State of licence issue USA 2 (ii) Category/Class of FAA certificate AEROPLANES: □ PPL □ CPL □ ATPL 3 Licence issue date Dd/mm/yyyy 4 (iv) Full name (Last and first names) LAST NAME, First name 5 (iv a) Date of birth (dd/mm/yyyy), or National ID number Dd/mm/yyyy …………………………………………. [PII not provided by FAA in airman verification process. The applicant must provide.] 6 (xiv) Other detail (for example Place of birth) Optional [PII not provided by FAA in airman verification process. The applicant must provide.] 7 (v) Address: - Permanent address: - Postal address: [PII not provided by FAA in airman verification process. The applicant must provide.] 8 Contact details: - Email: - Phone number: Personal contact details [PII not provided by FAA in airman verification process. The applicant must provide.] 9 (vi) Nationality Dutch [PII not provided by FAA in airman verification process. The applicant must provide.] 10 (viii) Issuing authority (conditions under which the licence was issued, where necessary) FAA 11 (xii) Valid and non-expired ratings/privileges and certificates held (Only Class or Instrument ratings) Ratings and certificates Issue date (dd/mm/YYYY) SEL xx/xx/xxxx 12.. Expired ratings: N/A 13 (xiii) Remarks, i.e., special endorsements relating to limitations, restrictions and endorsements for privileges (e.g.: language proficiency level and validity (English, others)) Special endorsements: Last Flight Review in English (for language request) Date (dd/mm/yyyy): 14. Details on completion of theoretical-knowledge or flight instruction, theoretical-knowledge examination or skill test in other Member States, if applicable : N/A 15 Past or pending enforcement action* Yes 🞏 No �� (If yes, please give details on a separate page.) 16 Is the licence in point 2 a validation issued by the FAA on the basis of a licence issued by another Contracting State to the Chicago Convention.** Yes 🞏 No 🞏 (Please add details hereunder) 17 Initial PART-MED medical certificate: Date of issue: xx/xx/xxxx Date of examination: xx/xx/xxxx Class: * Item 15 specify if there is a current investigation into the medical certificate and licence, or suspension or revocation thereof. ** Item 16: e.g. has it been rendered valid according 1.2.1 of Annex 1 of the Chicago Convent? I, (last name, first name) hereby apply for a PART-FCL licence or rating. Type of licence applied for: Private Pilot licence - Aeroplanes: None MEP(L) Night Rating IR(A) for SE IR(A) for ME Holder of a PART-FCL licence: Yes: No In case of holder of a PART-FCL Licence:ion?