The ATO confirms that the candidate has been trained according to the approved syllabus and assures the level of proficiency required.

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Georgina Rice
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1 Frl Dprtmnt o th Environmnt, Trnsport, Enry n Communitions DETEC Frl Oi o Civil Avition FOCA Sty Division Fliht Prsonnl 3003 Brn CPL(A) Skill tst Applition n rport orm Applint's lin numr: Applint lst nm: irst nm: t o irth: pl o irth: pl o oriin: ntionlity: privt rss: post o: ity: strt: phon/x hom: phon/x oi: -mil: initil skill tst omin with irst CR/TR rptition o il skill tst, rom t: initil skill tst omin with CR/TR pro. hk rptition o prtil pss skill tst, rom t: Instrutor lst nm: irst nm: lin numr: sintur o liht instrutor: Th ATO onirms tht th nit hs n trin orin to th pprov syllus n ssurs th lvl o proiiny rquir. ATO nm: ristrtion numr: nm o hi liht instrutor: lin numr: lotion & t: sintur o hi liht instrutor: 1 Dtils o liht t: typ o ropln: ristrtion: lss: TR: prtur/stintion lok-o: lok-on: lok tim: # o lnins: 2 Rsult o skill tst *lt s nssry Applint's sintur pss* il* prtil pss* 3 Rmrks Exminr: lst nm: irst nm: xminr uthoristion: lin numr: lotion n t: sintur o liht xminr: FOCA/EASA Form EASA Prt FCL Appnix 4 1/6

2 BAZL OFAC UFAC FOCA CH-3003 Brn (Switzrln) Applint's lin numr: Instrution / xprin rport A opy o th rlvnt loook ps (liht xprin & STD ps) showin th onirm ompltion o th liht instrution must tth to this orm. Pls mk sur to not your lin numr tothr with your sintur t th ottom o th ps. Summry o onitions n lyin xprin or CPL(A) skill tst ) Applint minimum : 18 yrs ) Pilot lin (mil or PPL) ) EASA Mil lss 1 (Prt MED.A.030 ()) ) Thortil xmintion CPL(A) pss ) Niht quliition omplt or onirm with orm t o issu: vli until: t: ntry in lin: t: ) Bor strtin CPL moulr ours pplint shll hv omplt: (150 HRs liht tim): hours: ) Mximum PIC hours Crits (Appnix 3, E, 12 ()): (i) 30 PIC hours on hlioptrs i holin PPL(H) ; or (ii) 100 PIC hours on hlioptrs i holin CPL(H) ; or (iii) 30 PIC hours on TMG or silplns; or (iv) 30 PIC hours on irships i holin PPL(As) ; or (v) 100 PIC hours on irships i holin CPL(As) ; A opy o th rlvnt loook ps must sumitt. hours: Gnrl liht xprin: (MNM 200 HR) hours: h) Fliht xprin s PIC (MNM 100 HR) hours: o whih ross ountry VFR s PIC (MNM 20 HR) hours: o whih 540 Km ross ountry liht: L 1 DEP DEST KM L 2 DEP DEST KM L 3 DEP DEST KM totl (MNM rt irl istn 540 Km) KM i) Dul visul liht instrution (MNM 15 HR) hours: For Pilots without IR: j) Dul instrumnt liht instrution (MNM 10 HR) hours: o whih instrution tim BITD,FNPT I or II,FFS (MAX 5 HR) hours: Minimum 5 HR instrution i) or j) ov must in n ropln itt with 4 sts, VP n RU. (MNM 5 HR) hours: FOCA/EASA Form EASA Prt FCL Appnix 4 2/6

3 BAZL OFAC UFAC FOCA CH-3003 Brn (Switzrln) Applint's lin numr: Conut o th skill tst An pplint shll pss ll pplil stions o th skill tst. I ny itm in stion is il, tht stion is il. Filur in mor thn on stion will rquir th pplint to tk th ntir tst in. An pplint ilin only on stion shll tk th il stion in. Filur in ny stion o th r-tst, inluin thos stions tht hv n pss on prvious ttmpt, will rquir th pplint to tk th ntir tst in. All stions o th skill tst shll omplt within six months. Furthr trinin my rquir ollowin ny on il skill tst. Filur to hiv pss in ll stions o th tst in two ttmpts will rquir urthr trinin s trmin y th Authority. Thr is no limit to th numr o skill tsts tht my ttmpt. Th Authority will provi th FE with qut sty vi to nsur tht th tst is onut sly. Shoul th pplint hoos to trmint skill tst or rsons onsir inqut y th FE, th pplint shll rtk th ntir skill tst. I th tst is trmint or rsons onsir qut y th FE, only thos stions not omplt shll tst in urthr liht. A th isrtion o th FE, ny mnouvr or prour o th tst my rpt on y th pplint. Th FE my stop th tst t ny st i it is onsir tht th pplint's monstrtion o lyin skills rquirs omplt r-tst. An pplint shll rquir to ly th ropln rom position whr th pilot-in-ommn untions n prorm n rry out th tst s i thr is no othr rw mmr. Rsponsiility or th liht shll llot in orn with ntionl rultions. Th rout to lown shll hosn y th FE n th stintion shll ontroll rorom. Th rout my n t th rorom o prtur or t nothr rorom. Th pplint shll rsponsil or th liht plnnin n shll nsur tht ll quipmnt n oumnttion or th xution o th liht r on or. Th urtion o th liht shll t lst 90 minuts. An pplint shll init to th FE th hks n utis rri out. Chks shll omplt in orn with th uthoris hk list or th ropln whih th tst is in tkn. Durin pr-liht prprtion or th tst th pplint is rquir to trmin powr sttins n sps. Prormn t or tk-o, pproh n lnin shll lult y th pplint in omplin with th oprtions mnul or liht mnul or th ropln us. Th FE will tk no prt in th oprtion o th ropln xpt whr intrvntion is nssry in th intrsts o sty or to voi unptl ly to othr tri. Hinwis: Innrt 10 Tn nh Zustllun s Ernisss s Skill Tsts/Proiiny Chks knn im Bunsmt ür Zivilluthrt, 3003 Brn, shritlih i Ausstllun inr shwrähin Vrüun ür s Prüunsrsultt vrlnt wrn. Rmrqu: Il st possil, ns ls ix jours suivnt l ommunition u résultt u Skill Tst/Proiiny Chk 'otnir, sur réquêt érit uprès l'oi éérl l'vition ivil, 3003 Brn, un éision susptil rours portnt sur l résultt uit xmn. Avviso: Entro ii iorni ll'invio i rsultti llo Skill Tst/Proiiny Chk può ssr rihist pr isritto ll'uiio rl ll'vizion ivil, 3003 Brn, un ision impunil sull'sito ll'sm. Rmrk: Within 10 ys tr ript o this skill tst/proiiny hk rsult, n ppll ision out th tst / hk rsults my rqust in writin to th Frl Oi o Civil Avition, 3003 Brn, usin on o th oiil lnus (Grmn/Frnh/Itlin) FOCA/EASA Form EASA Prt FCL Appnix 4 3/6

4 BAZL OFAC UFAC FOCA CH-3003 Brn (Switzrln) Applint's lin numr: Us o hklist, irmnship, A/C limittions must rspt in ll stions Stion 1 Pr-liht, inluin: Fliht plnnin, Doumnttion, Mss & ln trmintion, Wthr ri, NOTAM 1 ttmpt 2 ttmpt pss il pss il Pr-liht oprtions & prtur Aropln insption & srviin Txiin & tk-o Prormn onsirtions n trim Arorom n tri pttrn oprtions Dprtur prour, ltimtr sttin, ollision voin (lookout) ATC liison - omplin, R/T prours pls lt s nssry pss il xminr's sintur Stion 2 1 ttmpt 2 ttmpt pss il pss il Gnrl irwork * Control o th ropln y xtrnl visul rrn, inluin striht n lvl, lim, snt, lookout Fliht t ritilly low irsp inluin ronition o n Rovry rom inipint n ull stlls Turns, inluin Turns in lnin oniurtion. Stp turns 45 nk Fliht t ritilly hih irsp inluin ronition o n Rovry rom spirl ivs Fliht y rrn solly to instrumnts inluin: (i) (ii) (iii) (iv)* Lvl liht, ruis oniurtion, ontrol o hin, ltitu n irsp Climin n snin turns with nk Rovris rom unusul ttitus Limit pnl instrumnts ATC liison - omplin, R/T prours pls lt s nssry pss il xminr's sintur * My prorm in Fliht Simultor or FNPT II i rtii or this purpos FOCA/EASA Form EASA Prt FCL Appnix 4 4/6

5 BAZL OFAC UFAC FOCA CH-3003 Brn (Switzrln) Applint's lin numr: Us o hklist, irmnship, A/C limittions must rspt in ll stions Stion 3 Control o th ropln y xtrnl visul rrn, inluin Cruis oniurtion Rn / Enurn onsirtions 1 ttmpt 2 ttmpt pss il pss il En-rout prours Orinttion, Mp rin Altitu, sp, hin ontrol, lookout Altimtr sttin. ATC liison - omplin, R/T prours Monitorin o liht prorss, liht lo, ul us, ssssmnt o trk rror n r-stlishmnt o orrt trkin Osrvtion o wthr onitions, ssssmnt o trns, ivrsion plnnin Trkin, positionin (NDB or VOR), intiition o ilitis (instrumnt liht). Implmnttion o ivrsion pln to ltrnt rorom (visul liht) pls lt s nssry pss il xminr's sintur Stion 4 1 ttmpt 2 ttmpt pss il pss il Approh n lnin prours Arrivl prours, ltimtr sttin, hks, lookout ATC liison - omplin, R/T prours Go-roun tion rom low hiht Norml lnin, Crosswin lnin (i suitl onitions) Short il lnin Approh n lnin with il powr (sinl nin ropln only) Lnin without us o lps h Post liht tions pls lt s nssry pss il xminr's sintur FOCA/EASA Form EASA Prt FCL Appnix 4 5/6

6 BAZL OFAC UFAC FOCA CH-3003 Brn (Switzrln) Applint's lin numr: Us o hklist, irmnship, A/C limittions must rspt in ll stions Stion 5* 1 ttmpt 2 ttmpt This stion my omin with stions 1 throuh 4 pss il pss il Simult nin ilur tr tk-o (t s ltitu), ir rill Anorml & mrny prours Equipmnt mluntions inluin ltrntiv lnin r xtnsion, ltril n rk ilur For lnin (simult) ATC liison - omplin, R/T prours Orl qustions pls lt s nssry pss il xminr's sintur Stion 6* This stion my omin with stions 1 throuh 5 pss il pss il Simult nin ilur urin tk-o (t s ltitu unlss rri out in FFS or FNPT II) Simult symmtri liht n rlvnt lss/typ itms 1 ttmpt 2 ttmpt Asymmtri pproh n o-roun Asymmtri pproh n ull stop lnin Enin shut own n rstrt ATC liison - omplin, R/T prours As trmin y th FE - ny rlvnt itms o th lss/typ rtin skill tst to inlu, i pplil: (i) Aropln systms inluin hnlin o utopilot (ii) Oprtion o prssuristion systm (iii) Us o -iin n nti-iin systm Orl qustions pls lt s nssry pss il xminr's sintur * My prorm in Fliht Simultor or FNPT II i rtii or this purpos By sinin this orm, I lr: ) ) ) ) I o not possss pilot lin, rtiit, rtin, uthoristion or ttsttion with th sm sop n in th sm tory issu in nothr EASA Mmr Stt. I hv not ppli or pilot lin, rtiit, rtin, uthoristion or ttsttion with th sm sop n in th sm tory issu in nothr EASA Mmr Stt. I hv nvr possss ny prsonnl lin, rtiit, rtin, uthoristion or ttsttion with th sm sop n in th sm tory issu in nothr EASA Mmr Stt whih ws rvok or suspn in ny othr EASA Mmr Stt. tht th inormtion provi r orrt. I m wr o th onsquns o proviin ls inormtion, suh s in ni lins, rtiit, rtin, uthoristion or ttsttion, or hvin it rvok or nll. Nm: Sintur o pplint: Dt n pl: FOCA/EASA Form EASA Prt FCL Appnix 4 6/6

place of birth: place of origin: nationality: initial skill test repetition of failed / partially passed skill test, from date:

place of birth: place of origin: nationality: initial skill test repetition of failed / partially passed skill test, from date: Frl Dprtmnt o th Environmnt, Trnsport, Enrgy n Communitions DETEC Frl Oi o Civil Avition FOCA Sty Division Flight Prsonnl 3003 Brn LAPL(A) Skill tst Applition n rport orm Applint lst nm: irst nm: t o irth: