Dac Form 710-1 - Application For Student/initial/variation/continuity/renewal Of Air Traffic Controller Licence
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1
2Grand-Duchy of Luxembourg
APPLICATION FOR STUDENT / INITIAL /
VARIATION / CONTINUITY / RENEWAL
OF AIR TRAFFIC CONTROLLER LICENCE
Direction de l’Aviation Civile
A. APPLICANT’S DETAILS (mandatory)
1. Name
2. Address
3. Nationality
4. Date and place of birth
5. Date
6. E-mail
7. Phone/Mobile
B. LICENSE DETAILS (if applicable)
1. Licence N°
2. Date of first issue
C. EMPLOYER’S DETAILS (mandatory)
1. Name
2. Phone
3. Address
D. APPLICATION (mandatory)
Application for:
Explanation
Valid until
Initial Student Licence
After initial training and before on-the-job-training
Initial Controller
After on-the-job-training and release
Licence
Variation
To add changes to a licence (new rating, new endorsement…)
Continuity
Extension of endorsements after periodic competence assessment
After suspension of a licence and successful on-the-job-training and
Renewal
release
E. APPLICATION FOR LANGUAGE ENDORSEMENT (if applicable)
Language endorsement
Valid until
I wish to apply for initial / variation / continuity / renewal of my ATC licence as indicated and confirm that the information
contained in this form was correct at the time of application.
I herewith confirm that:
1. I am not holding an ATC licence issued by another Member State,
2. I never had an ATC licence issued by another Member State which was revoked or suspended in any other Member
State.
I also understand that any incorrect information could disqualify me from holding an ATC licence.
Name
Signature of applicant
Date
Mar2012
Page 1/2
DAC Form 710-1
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