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Office .DPSXV8QLYHUVLWDV.HEDQJVDDQ-OQ7HUXVDQ+DOLPXQ1R%DQGXQJ- Indonesia

Telp.: (+622) , Fax. : (+622) 
Website : ZZZGDWFFRLG

INSTRUCTOR / CHECKER FOR PILOT, FOO, FE, AND FA APPLICATION

I. Application information
[ ] Ground Instructor [ ] Flight Instructor Instrument [ ] CCP Line Check All Seat [ ] Company Checker
[ ] Flight Instructor Simulator [ ] CCP Prof Check on Simulator [ ] CCP Observer Only [ ] Initial / Renewal
[ ] Flight Instructor Airplane [ ] CCP Prof Check on Aircraft [ ] Company Instructor [ ] Others : ___________________

A. Name (Full) B. KTP/Passport C. Date of Birth D. Place of Birth (City, Country)

E. Address (KTP/Passport) F. Nationality Specify G. Do you read, speak and understand

English?
[ ] Indonesian [ ] Other ___________
[ ] Yes [ ] No

H. Height (cm) I. Weight (kg) J. Sex

L. License / Certificate No. M. Date Issued

N. Do you hold a [ ] Yes O. Class of Certificate P. Date Issued Q. Name of Examiner

Medical Certificate? [ ] No

R. Have you ever been convicted for violation of any laws pertaining to S. Date of Final Conviction
Narcotic drugs, marijuana, and depressant or stimulant drugs or substances, or motor [ ] No
Vehicle operation involving alcohol related offenses? [ ] Yes

II. Applicant’s Certification: A. Name & Signature B. Date

I certify that the statements made by me on this application are true.

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POI Recommendation:
I have personally instructed the applicant and consider this person ready to take the test

Date  POI Name & Signature

[ ] I have personally renewed this applicant’s Training Record and Approved Training Program Manual certify that the individual meets the pertinent requirements of all applicable
requirements.

DGCA Inspector’s Report

Evaluator’s record
Inspector Examiner Name & Signature Date of Completion
Oral and Demonstrate Presentation [ ] [ ] ________________________________ _____________________
Approved Simulator/Training Device Check [ ] [ ] ________________________________ _____________________
Aircraft flight check [ ] [ ] ________________________________ _____________________

I have personally tested this applicant in accordance with or have otherwise verified that this applicant complies with pertinent procedures, standards, polices and or necessary requirements
with the result indicated below:
[ ] Approved [ ] Disapproved – Disapproval Notice Issued

Location of test (Facility, City, Country) Duration of Test (hours)

Ground : Simulator /Training Device : Flight :

Aircraft Rating for which tested Type(s) of aircraft used for test Aircraft Registration No.(s) used for test

Date Inspector’s Name & Signature DGCA Office

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