540 Form Pel - Validate License Gcaa - Ghana Civil Aviation Authority

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A
F
INSTRUCTIONS
PPLICATION
OR
Print or type. Do not write in shaded areas, these are for
L
V
C
ICENSE
ALIDATION OR
ONVERSION
GCAA use only. Submit original only to the Safety
Regulations Department or a GCAA Authorized Person. If
B
F
L
ASED ON A
OREIGN
ICENSE
additional space is required, use an attachment
A. APPLICATION IS HEREBY MADE FOR ISSUANCE, RE-ISSUANCE OR RENEWAL OF A GHANA LICENSE BASED ON VALIDATION OR CONVERSION OF A FOREIGN LICENSE:
1
ADDED RATING
4
MEDICAL CERTIFICATE
7
FLIGHT INSTRUCTOR
A IRCRAFT MAINTENANCE ENGINEER
2
PILOT
5
8
FLIGHT DISPATCHER
3
FLIGHT ENGINEER
6
INSPECTION AUTHORIZATION
9
FLIGHT NAVIGATOR
B. AIRMAN PERSONAL INFORMATION
:
1. NAME (
)
2. PERMANENT ADDRESS (
)
Last, First, Middle
Street or PO Box Number
3. TELEPHONE AND FAX
4. CITY
/STATE/PROVINCE
MAIL CODE
COUNTRY
5. DATE OF BIRTH
6. PLACE OF BIRTH
7. NATIONALITY (
)
8. LANGUAGE
(MONTH, DAY, YEAR)
CITIZENSHIP
Yes
PROFICIENCY
LEVEL 4?
No
9. HEIGHT
10. WEIGHT
11. HAIR
12. EYES
13. SEX
14. E-MAIL ADDRESS
15. For GCAA Use
C. PILOT INFORMATION:
1. LICENSE NUMBER
2. STATE OF ISSUE
3. DATE ISSUED
4. RATING(S) REQUESTED
5. TOTAL FLIGHT HRS
6. TOTAL PIC HRS
7. TOTAL X-C HRS
8. TOTAL NIGHT HRS
9. INSTRUMENT PIC
10. TOTAL HRS TYPE
11. RATINGS AND LIMITATIONS TO BE ISSUED
12. ASSIGNED NUMBER AND EXPIRATION DATE
D. OTHER LICENSE INFORMATION:
1. LICENSE NUMBER
2. STATE OF ISSUE
3. DATE ISSUED
4. RATING(S) REQUESTED
5. RATINGS AND LIMITATIONS TO BE ISSUED
6. ASSIGNED NUMBER AND EXPIRATION DATE
E. MEDICAL EVALUATION INFORMATION:
1. CLASS OF CERTIFICATE
2. STATE OF ISSUE
3. DATE OF ISSUE
4.MEDICAL EXAMINER
G.
ATTACH APPLICANT PHOTO HERE
(Passport Size)
5. LIMITATIONS OR RESTRICTIONS TO BE ISSUED
6. ASSIGNED NUMBER AND EXPIRATION DATE
F. APPLICANT’S CERTIFICATION—
I certify that all statements and answers provided by me on this application form are complete and true to the
best of my knowledge and I agree that they are to be considered as part of the basis for issuance of any Ghana license to me.
A person shall not with intent to deceive: (c) make
1. DATE
2. APPLICANT SIGNATURE:
any false representation for the purpose of
procuring for himself or any other person the
grant, issue, renewal or variation of any such
license...
:
H. GCAA AUTHORIZED PERSON CERTIFICATION
1. LANGUAGE PROFICIENCY TEST ADMINISTERED
3. CONFIRMATION CONTACT MADE WITH ISSUING CIVIL AVIATION AUTHORITY
TELEPHONE:____________________
NAME: _______________________________ .
2. RECOMMEND ISSUANCE OF LICENSE
ICAO CONTRACTING STATE: ______________________________________________
.
4. DATE
5. TITLE OR DESIGNATION NUMBER
6. SIGNATURE
7. CASORT ENTRY:
Copies of all issued Ghana
Copy of other State's medical
Last 12 months experience reviewed
Copy of applicable aircraft-specific training
license(s) attached
evaluation attached
(required for Inspection Authorization)
or experience attached
Copy of other State's airman
Airman logbook reviewed for
Copy of aircraft lease reviewed for
Other relevant experience or training
license(s) attached
experience requirements
applicable time period
documents attached
GCAA Form 540 [0]2010
Control Number:

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