Form Srg 1411a - Application For The Initial Issue Of An Air Traffic Controller (Atco) Licence

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Application for the Initial Issue of an Air Traffic Controller (ATCO) Licence

(Commission Regulation (EU)2015/340)

Please complete this form online (preferred method) then print and sign the form.

Alternatively, print, then complete in BLOCK CAPITALS using black or dark blue ink.

Post or scan and email the form in accordance with Section 8.

Please read the attached guidance notes before completing the form .

FALSE REPRESENTATION STATEMENT

It is an offence under Article 256 of the Air Navigation Order 2016 to make, with intent to deceive, any false representation for

the purpose of procuring the grant, issue, renewal or variation of any certificate, licence, approval, permission or other document.

This offence is punishable on summary conviction by a fine up to £5000, and on conviction on indictment with an unlimited fine or up

to two years imprisonment or both.

1. PERSONAL DETAILS (Complete as shown on passport)

(Completed by the Applicant)

Serial Number of Student Licence

Title: ............. Surname: ...............................................................

Forename(s) ..................................................................................

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

Nationality .......................................................................................

Place of Birth:

...............................................................................

Country of Birth: .............................................................................

Applicants Address:

...............................................................................................................................................................................

County: .................................................. Country: ............................................. Postcode: .................................

Telephone Numbers:

Home: ................................................................ Mobile: ....................................................................................

Email Address: .....................................................................................................................................................

Unit Address:

..............................................................................................................................................................................

.............................................................................................................................................................................

ICAO Location Indicator:

County: .................................................. Country: ............................................. Postcode: .................................

2. NOTIFICATION OF UNIT ENDORSEMENT ASSESSMENT

(Completed by the Applicant)

Location of assessment: .................................................................

Proposed date ( dd/mm/yyyy ): ........................................................

3. RATING/ENDORSEMENT TO BE ASSESSED

(Completed by the Applicant)

Unit Endorsement Sector/Position(s) (if appropriate): .................................................................................................................................

Rating

Rating Endorsement

Description

ADV Aerodrome Control Visual

ADI Aerodrome Control Instrument

TWR

Tower Control

AIR

Air Control

RAD

Aerodrome Radar

GMC