EIR(A) AEROPLANE SKILLTEST PROFICIENCY CHECK SE ME Application and report form A. Udfyldes af ansøgeren/to be filled out by the applicant:

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1 EIR(A) AEROPLANE SKILLTEST PROFICIENCY CHECK SE ME Applition n rport form A. Ufyls f nsøgrn/to fill out y th pplint: CPR-nr./Dt of Birth: Crtifikt nr./lin no.: (If ny) Ustn Stt/Stt of Lin Issu: Fornvn/First nm(s): Eftrnvn/Lst nm: G llr vj:/strt: Postnr. og y/postl o n ity: -mil: Tlf./Tlphon: Dto for unrskrift/dt of signtur: Unrskrift/Signtur: B: Ufyls f skoln/to fill out y ATO: Nm of ATO: (Us stmp): Spifition of flight tim Totl: IFR rout stors Cross-Country:PIC Instrumnt Flight Instrution Instrumnt Groun tim: Night:Qulifition optin t? Criting of flight tim (tth oumnttion) I hry rtify tht th pplint hs pss th rquir trining n tht th pplint fulfils th rquirmnt for th issu of Instrumnt Rting (Aropln) Dt of signtur of H of Trining Signtur of H of Trining C: To fill out y th Exminr: Dt of tst: Lin Enorsmnt: Typ of irrft: Nm of Exminr or stmp: Stmp of Exminr, Authoristion no. of Exminr or stmp: I hry vrify tht th pplint hs pss th rquir trining n tht th pplint fulfills th rquirmnt for th issu of Enrout Instrumnt Rting (Aropln) Dt of signtur of Exminr Signtur of Exminr Stion 1: Pss Finl rsult: Fil Stion 2: Pss Fil Stion 3: Rsult of th tst Stion 4: Stion 5: Pss Fil Pss Fil Pss Fil Tmporry lin issu (opy nlos): Stion 6: Not Applil Pss Fil Pss Prtil Pss Fil Ys No Vli until: EIR(A) DEC 2014 Pg 1 of 5 Trfikstyrlsn, Evr Thomsns Vj 14, 2300 Kh. S., Tlf.: , -mil: info@trfikstyrlsn.k

2 For til instrutions s AMC1 FCL.825(); (g) En rout instrumnt rting (EIR) Us of hklist, irmnship, nti-iing/-iing prours, t., pply in ll stions Nm of Applint: SECTION 1 PRE-FLIGHT OPERATIONS AND DEPARTURE Pss Fil f g h Us of flight mnul (or quivlnt) spilly / prformn lultion, mss n ln Us of Air Trffi Srvis oumnt; wthr oumnt Prprtion of ATC flight pln; IFR flight pln/log Pr-flight insption Wthr Minim Txiing Pr-tk off rifing; Tk off ATC liison omplin; R/T prours SECTION 2 GENERAL HANDLING Pss Fil Control of th ropln y rfrn solly to instrumnts, inluing: lvl flight t vrious sps, trim. Climing n sning turns with sustin Rt 1 turn Rovris from unusul ttitus, inluing sustin 45 nk turns n stp sning turns Rovry from pproh to stll in lvl flight; liming/sning turns n in lning onfigurtion Limit pnl, stilis lim or snt t Rt 1 turn onto givn hings, rovry from unusul ttitus. SECTION 3 EN-ROUTE IFR PROCEDURES Pss Fil F g H I J K l Trnsition to instrumnt flight Trking, inluing intrption,.g. NDB; VOR; RNAV Us of rio is Lvl flight, ontrol of hing, ltitu n irsp, powr stting, trim thniqu Altimtr stting Timing n rvision of ETAs (En-rout hol if rquir) Monitoring of flight progrss, flight log, ful usg, systms mngmnt Simult mrgny sitution(s) I prottion prours, simult if nssry Simult ivrsion to ltrnt rorom Trnsition to visul flight ATC liison omplin, R/T prours EIR(A) DEC 2014 Pg 2 of 5

3 For til instrutions s AMC1 FCL.825(); (g) En rout instrumnt rting (EIR) Us of hklist, irmnship, nti-iing/-iing prours, t., pply in ll stions Nm of Applint: SECTION 4 Pss Fil Intntionlly lft lnk SECTION 5 Pss Fil Stting n hking of nvigtionl is, intifition of filitis Arrivl prours, ltimtr sttings Approh n lning rifing, inluing snt/pproh/lning hks Visul lning ATC liison omplin, R/T prours SECTION 6 (If pplil) Flight with on ngin inoprtiv Simult ngin filur uring n rout phs of flight ATC liison omplin; R/T prours Pss Fil EIR(A) DEC 2014 Pg 3 of 5

4 For til instrutions s AMC1 FCL.825(); (g) En rout instrumnt rting (EIR) Us of hklist, irmnship, nti-iing/-iing prours, t., pply in ll stions Nm of Applint: Dtils of th flight Airrft rgistrtion On lok On groun Dprtur rorom Off lok Airorn Dstintion rorom Totl lok tim Totl irorn tim No. of lnings: Rmrks/Ovrll ssssmnt/rsons for filur (if pplil): Nm of instrutor prsnt t th Skill Tst: Signtur of Exminr Signtur of Applint: EIR(A) DEC 2014 Pg 4 of 5

5 For til instrutions s AMC1 FCL.825(); (g) En rout instrumnt rting (EIR) Us of hklist, irmnship, nti-iing/-iing prours, t., pply in ll stions Nm of Applint: In orn with ARA.GEN.315(), () () Unrtgn kræftr hrm, t jg v nsøgningstispunktt Not: 1. ikk vr ikk i sils f t prsonligt rtifikt, rting, tillls llr ttsttion m smm nvnlssområ og i smm ktgori ustt i n nn mlmsstt; 2. ikk hr nsøgt om t prsonligt rtifikt, rting, tillls llr ttsttion m smm nvnlssområ og i smm ktgori i n nn mlmsstt; og 3. lrig hr hft t prsonligt rtifikt, rting, tillls llr ttst m smm nvnlssområ og i smm ktgori ustt i n nn mlmsstt, som r tilgklt llr suspnrt i nn mlmsstt. Ukorrkt oplysningr vrørn ovnstån, kn vær iskvlifirn for ustls f rtifikt, rting, tillls m.v. Unrsign hry onfirm tht I t th tim of pplition 1. ws not holing ny prsonnl lin, rtifit, rting, uthoristion or ttsttion with th sm sop n in th sm tgory issu in nothr Mmr Stt; 2. hs not ppli for ny prsonnl lin, rtifit, rting, uthoristion or ttsttion with th sm sop n in th sm tgory in nothr Mmr Stt; n 3. hs nvr hl ny prsonnl lin, rtifit, rting, uthoristion or ttsttion with th sm sop n in th sm tgory issu in nothr Mmr Stt whih ws rvok or suspn in ny othr Mmr Stt. 4. Not: Inorrt informtion rgring th ov n isqulifying for otining rtifit, rting, uthoriztion, t. Dto:/Dt: Unrskrift:/Signtur: EIR(A) DEC 2014 Pg 5 of 5

Result of the test Section 4:

Result of the test Section 4: SKILL TEST IR(A) AEROPLANE SE ME Applition n rport orm A. Uyls nsøgrn/to ill out y th pplint: Dt o Birth: Crtiikt nr./lin no.: (I ny) Ustn Stt/Stt o Lin Issu: Fornvn/First nm(s): Etrnvn/Lst nm: G llr vj:/strt: