APPLICATION FOR ISSUE/REVALIDATION/RENEWAL OF (STUDENT) AIR TRAFFIC CONTROLLER (ATCO) LICENCE, RATINGS AND ENDORSEMENTS

Part A: APPLICANT’S DETAILS

Name: 

Permanent address:…………………………………………………………………………………………………………………

Tel.:……………………………………… Mobile:………………… E-mail address:…………………………………………

Nationality: ………………

Date (dd/mm/yyyy) and place of birth:…………………………………………………………………………….

(STUDENT) ATCO LICENCE DETAILS (if applicable):

Licence serial No:……………………………………
Date of issue (dd/mm/yyyy): ………………………………

EMPLOYER’S DETAILS (if applicable):

Name: 

Part B: APPLICATION FOR (Tick the relevant boxes)

Issue of Student ATCO Licence, rating(s) and rating endorsements) (Part C, E and F of this form)

Language endorsement(s) (Part C, E and F of this form)

Issue of ATCO Licence, rating(s) and rating endorsements) (Part C, E and F of this form)

Revalidation of ATCO Licence rating, endorsements (Part C, D, E and F of this form)

Renewal of ATCO Licence rating, endorsements (Part C, D, E and F of this form)

Part C: RATING/RATING ENDORSEMENT/ATC UNIT/Sector

ADI 

(Unit, sector, working position)

TWR

GMC

GMS

AIR

RAD

APS 

(Unit, sector, working position)

PAR 

SRA

TCL

ACS 

(Unit, sector, working position)

TCL  

OCN

ACP 
  

(Unit, sector, working position)

OCN

ADV 
 

(Unit, sector, working position)

APP 
 

(Unit, sector, working position)

Licence endorsements

OJTI

STDI

Assessor

Language proficiency endorsement

- level 4

- level 5

- level 6

Local (specify language) _ language proficiency endorsement*

- level 4

- level 5

- level 6

* Optional, if imposed by the Member State for reasons of safety at the ATC unit as published in AIP.

Part D: Unit endorsement revalidation/renewal

The applicant meets the requirements according to Regulation (EU) .…/…. and to the unit competence scheme of unit ……………………………………………………………………….

The unit/licence endorsements annotated below are revalidated/renewed * (delete as appropriate).
Based on this, REVALIDATION/RENEWAL can be done as listed below:

Unit endorsement:

Valid until:

Unit endorsement:

Valid until:

Unit endorsement:

Valid until:

Unit endorsement:

Valid until:

Unit endorsement:

Valid until:

Unit endorsement:

Valid until:

I certify that the data is complete and true

Authorised assessor: 

Name:

Assessor’s licence number:

Signature:

Part E: Declaration

I hereby:

1. apply for the issue/revalidation/renewal of (Student) ATCO Licence, ratings and/or endorsements as indicated;

2. confirm that the information contained herein is correct at the time of the application;

3. confirm that I am not holding any (Student) ATCO Licence issued in another Member State;

4. confirm that I have not applied for any (Student) ATCO Licence in another Member State; and

5. confirm that I have never held a (Student) ATCO Licence issued in another Member State which has been revoked or suspended in any other Member State.

I understand that any incorrect information provided herein could prohibit me from holding a (Student) ATCO Licence.

Signed: . . . . . . . . . . . . . . . . . . . . Name: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Date (dd/mm/yyyy): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Part F: Certificates/Documents

Please enclose all relevant certificates and/or documents:

1. Copy of Student ATCO Licence, if applicable                                                     

2. Copy of passport or other national ID                                                               

3. Copy of medical certificate                                                                                 

4. Copy of relevant training certificate/documents proving the successful completion of:

(a) Initial training (integrated)                                                                                  

(b) Basic training                                                                                                          

(c) Rating training                                                                                                       

(d) Unit training                                                                                                            

(e) Practical instructor training                                                                                 

(f) Assessor training                                                                                                     

(g) Refresher training                                                                                                  

5. Copy of language proficiency certificate(s): language(s)                                 

6. Certificate by ATC provider

proving that the licence holder has fulfilled the requirements in accordance with the approved unit competence scheme                                                                                                                

7. Copy of the competence assessment form                                                          

8. Copy                                                                                                                             

APPLICATION FOR THE ISSUE/REVALIDATION/RENEWAL OF (STUDENT) AIR TRAFFIC CONTROLLER (ATCO) LICENCES, RATINGS AND ENDORSEMENTS

Part A: APPLICANT’S DETAILS

Name: 

Permanent address:…………………………………………………………………………………………………………………

Tel.:……………………………………… Mobile:………………… E-mail address:…………………………………………

Nationality: ………………

Date (dd/mm/yyyy) and place of birth:…………………………………………………………………………….

(STUDENT) ATCO LICENCE DETAILS (if applicable):

Licence serial number:……………………………………
Date of issue (dd/mm/yyyy): ………………………………

EMPLOYER’S DETAILS (if applicable):

Name: 

Part B: APPLICATION FOR (Tick the relevant boxes)

Issue of Student ATCO licence, rating(s) and rating endorsement(s) (Part C, E and F of this form)

Language proficiency endorsement(s) (Part C, E and F of this form)

Issue of ATCO licence, rating(s) and rating endorsement(s) (Part C, E and F of this form)

Revalidation of ATCO licence rating(s) and rating endorsement(s) (Part C, D, E and F of this form)

Renewal of ATCO licence rating(s) and rating endorsement(s) (Part C, D, E and F of this form)

Part C: RATING/RATING ENDORSEMENT/ATC UNIT/Sector

ADC 

(Unit, sector, working position)

SUR

APS 

(Unit, sector, working position)

PAR 

SRA

ACS 

(Unit, sector, working position)

OCN

ACP 
  

(Unit, sector, working position)

OCN

ADV 
 

(Unit, sector, working position)

APP 
 

(Unit, sector, working position)

Licence endorsements

OJTI

STDI

Assessor

Language proficiency endorsement

- level 4

- level 5

- level 6

Local (specify language): ___ language proficiency endorsement*

- level 4

- level 5

- level 6

* Optional, if imposed by the Member State for safety reasons at the ATC unit as published in the AIP.

Part D: Unit endorsement revalidation/renewal

The applicant meets the requirements of Regulation (EU) …/… and of the ……unit competence scheme.

The unit endorsements annotated below are revalidated/renewed (insert as appropriate).

Unit endorsement:

Valid until:

Unit endorsement:

Valid until:

Unit endorsement:

Valid until:

Unit endorsement:

Valid until:

Unit endorsement:

Valid until:

Unit endorsement:

Valid until:

I certify that the data is complete and true.

Authorised assessor: 

Name:

Assessor’s licence number:

Signature:

Part E: Declaration

I hereby:

1. apply for the issue/revalidation/renewal of (Student) ATCO licence, ratings and/or endorsements, as indicated;

2. confirm that the information contained herein is correct at the time of the application;

3. confirm that I do not hold any (Student) ATCO licence issued in another Member State;

4. confirm that I have not applied for any (Student) ATCO licence in another Member State; and

5. confirm that I have never held a (Student) ATCO licence issued in another Member State which has been revoked or suspended in any other Member State.

I understand that any incorrect information provided herein could prohibit me from holding a (Student) ATCO licence.

Signature: . . . . . . . . . . . . . . . . . . . . Name: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Date (dd/mm/yyyy): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Part F: Certificates/Documents

Please enclose all relevant certificates and/or documents:

1. Copy of Student ATCO licence, if applicable                                                     

2. Copy of passport or other national ID                                                               

3. Copy of medical certificate                                                                                 

4. Copy of relevant training certificate/documents proving the successful completion of:

(a) Initial training (integrated)                                                                                  

(b) Basic training                                                                                                          

(c) Rating training                                                                                                       

(d) Unit training                                                                                                            

(e) Practical instructor training                                                                                 

(f) Assessor training                                                                                                     

(g) Refresher training                                                                                                  

5. Copy of language proficiency certificate(s): language(s)                                 

6. Certificate by ATC provider

proving that the licence holder has fulfilled the requirements in accordance with the approved unit competence scheme                                                                                                                

7. Copy of the competence assessment form                                                          

8. Any other copy(ies), as necessary                                                                         

LICENCE VERIFICATION FORM

This form should be filled in and signed by the issuing competent authority of the licence being transferred.

ITEM

DESCRIPTION

1

State of licence(s) issue

Country

2

Title of licence

ATCO or Student ATCO

3

Licence issue date

4

Full name

(Last and first names)

LAST NAME 1, LAST NAME 2, etc.

First name 1, First name 2, etc.

5

Date of birth (dd/mm/yyyy)

xx/xx/xxxx

6

Address

(if indicated on the licence)

7

Contact details:

email:

phone number:

e.g.

example [at] example.eu

+(country code) xxxxxxxx

8

Nationality

Country

9

Transferring competent authority 

Country and authority

10

Valid and non-expired unit, instructor and assessor endorsements held

Endorsements

Valid until (dd/mm/yyyy)

e.g.

EDDK APS/SRA

xx/xx/xxxx

e.g.

OJTI

STDI

Assessor

xx/xx/xxxx

11

Ratings and rating endorsements held

Ratings and rating endorsements

Date of first issue

(dd/mm/yyyy)

e.g.

ADI

ACS

RAD

PAR

xx/xx/xxxx

12

Remarks, i.e. licence endorsements relating to language proficiency level and validity (English, others)

Language proficiency endorsements

Language

Level

Validity (dd/mm/yyyy)

13

Past or pending enforcement action*

Yes  No  (If yes, please provide details on a separate page.)

SUMMARY OF MEDICAL HISTORY — FORM FOR THE TRANSFER OF ATCO MEDICAL RECORDS

MEDICAL CONFIDENTIALITY SHALL BE ENSURED AT ALL TIMES AS PER POINT ATCO.MED.A.015

Item

Description

1

State of licence(s) issue

Country

2

Title of licence and corresponding serial number of the licence(s) held
(or national medical reference number)

UN country code ATCO.xxx

3

Full name

(Last and first names)

LAST NAME 1, LAST NAME 2, etc.

First name 1, First name 2, etc.

4

Date of birth (dd/mm/yyyy)

dd/mm/yyyy

5

Address

6

Contact details:

(a) email:

(b) phone number:

e.g.

(a) example [at] example.eu

(b) +(country code) xxxxxxxxxx

7

Nationality

Country

8

Transferring authority

Country and authority

9

Initial medical certificate or the first medical certificate available in the competent authority:

Date of issue

dd/mm/yyyy

Date of examination

dd/mm/yyyy

Type (European Class 3, Part ATCO.MED, or national)

10

Dates of last three

revalidation/renewal examinations (if any)

11

Limitations (if any)

12

Comments on any relevant aspect of the applicant’s medical history or examination (if appropriate, please enclose reports).

Enclose as minimum the examinations and investigation results as required by AMC1 ATCO.AR.D.003 Change of competent authority, point (a).

13

Past or pending enforcement action*

Yes                                     No 

(If yes, please provide details on a separate page.)

Certification

I, Dr ……………………………, medical assessor of the (competent authority name)………………………., certify that the details given above and on any additional pages included are true and correct.

Date

Signature

Transferring authority and stamp/seal