Application for Issue of an Instructor Certificate in Accordance with CAD FCL (Part-FCL) Please complete this form online (preferred method) then print, sign and submit as instructed. Alternatively, print, then complete in BLOCK CAPITALS using black or dark blue ink. Reference Number (to be completed by SCAA) Please read attached Guidance Notes before completing this form. FALSE REPRESENTATION STATEMENT It is an offence to make, with intent to deceive, any false representations for the purpose of procuring the grant, issue, renewal or variation of any certificate, licence, approval, permission or other document. Persons doing so render themselves liable and subject to prosecution under the current applicable regulations. 1. APPLICANT DETAILS (The Applicant is responsible for payment of SCAA charges) To be completed by the Applicant SCAA Personal reference number (if known): Title:... Forename(s):... Surname:... Date of birth (dd/mm/yyyy):... Nationality:... Town of birth:... Country of birth:... Permanent Address:...... Telephone:... Alternative telephone Number:... E-mail:... Fax Number:... 2. ADDRESS FOR CORRESPONDENCE (if different from above) To be completed by the Applicant Postal Address:............ 3. MEDICAL FITNESS To be completed by the Applicant Class of Medical Certificate held Date of last Medical Date of Expiry SCAA use only Note: Your Medical Certificate must be valid on the licence issue date. If your Medical Certificate is due to expire within 14 days after the date of application for licence issue, please complete the following My medical examination will take place at:... on:... Form SR FCL 1131 Issue 06 Page 1 of 8
4. PARTICULARS OF SEYCHELLES OR OTHER ICAO LICENCES HELD To be completed by the Applicant Issuing Authority Type/Class of Licence Licence Number Expiry Date 5. RATINGS HELD To be completed by the Applicant Please give the date of the most recent Skill Test (LST), Licensing Proficiency Check (LPC) or Revalidation by Experience for each type and/or class rating, and any Instructor certificate to be endorsed on your Part-FCL Licence. Rating or Certificate held Single- Pilot (SP) or Multi- Pilot (MP) Date of Test Date of IR Test (if applicable) Expiry Date of Rating Examiners Licence Number and Name SCAA Use Only 6. APPLICATION (See Guidance Notes) (tick as appropriate) To be completed by the Applicant I am applying for: Flight Instructor FI (A) FI (H) FI (B) FI (AS) FI (S) Type Rating Instructor TRI(A) (Please specify type)... Type Rating Instructor TRI(H) (Please specify type)... Type Rating Instructor TRI(PL) (Please specify type)... Class Rating Instructor CRI SE ME SE & ME Instrument Rating Instructor IRI (A) IRI (H) IRI(AS) Synthetic Flight Instructor SFI (SPA) (MPA) (H) (PL) Multi-Crew Cooperation Instructor MCCI Flight Test Instructor FTI Synthetic Training Instructor STI (A) (H) (Applicants for the STI only please got to section 9) Form SR FCL 1131 Issue 06 Page 2 of 8
7. PRE-COURSE FLIGHT EXPERIENCE (FI ONLY): To be completed by the Applicant FI(A) FI (H) FI(As) FI(B) FI(S) Total flight time (FCL.915.FI) Total flight time as Pilot In Command (PIC) (FCL.915.FI) Total flight time on Single Engine Piston Powered Aeroplanes (FCL.915.FI (b)(3) Total flight time VFR Cross Country as PIC (FCL.915.FI (a)(2) Date of 540km (300 nm) cross country flight (FCL.915 FI(b)(4) Instrument flight instruction (FCL.915.FI (a)(1) Total number of launches as PIC of Sailplanes (FCL.915.FI (e) Total flight time on Class of Balloon (FCL.915.FI(f) 8. PRE-COURSE FLIGHT EXPERIENCE (CRI/IRI/TRI/SFI/MCCI/FTI): To be completed by the Applicant Total flight time Aircraft (FCL.915.TRI), (FCL.915.CRI), (FCL.915.IRI) Total flight time on Multi Pilot Aircraft (FCL.915.TRI), (FCL.915.SFI(c), (FCL.915.MCCI(b) Route sectors in preceding 12 months in accordance with (FCL.915.TRI), (FCL.915.SFI(c)(2) Total flight time as Pilot in Command (PIC) for Single Pilot Multi Engine Aircraft, (FCL.915.TRI(d)(2), (FCL.915.CRI(a) Flight time on aeroplanes including flight time on type as PIC (FCL.915.TRI(c)(2), (FCL.915.CRI(b) Total Flight time in accordance with IFR in aircraft (FCL.915.IRI) Total Flight time in accordance with IFR in Flight simulator (FCL.915.IRI) Number of Category 1 or 2 Flight Test conducted (FCL.915.FTI) TRI MCCI CRI IRI SFI FTI 9. SYNTHETIC TRAINING INSTRUCTOR PRE-REQUISITE REQUIREMENTS (Aeroplane and Helicopter) STI(A&H) only To be completed by the Applicant I certify that... has completed the relevant Proficiency Check within the preceding 12 months in the following Class / Type... on (date)... STI(H) only I certify that... has completed at least one hour as an observer on the flight deck of the following helicopter type... on (date)... Form SR FCL 1131 Issue 06 Page 3 of 8
10. SYNTHETIC TRAINING INSTRUCTOR COURSE COMPLETION (Aeroplane and Helicopter) To be completed by the ATO conducting the Training I certify that (name)... has satisfactorily completed an approved course of training in accordance with Part-FCL for the following course: STI (A) (H) on the following simulator: FNPTII/III FTD 2/3 FFS Total hours of flight instruction related to duties of STI on course:... hrs FSTD Identification Number of simulator used (which must be issued in accordance with CAD ARA:... Competent Authority issuing Qualification certificate for the simulator:... Approved Training Organisation:... ATO Approval No:... Competent Authority issuing Approval:... Name of Head of Training:... Signature (Head of Training):... Date:... Applicants for the STI only please go to Section 15. 11. CONFIRMATION OF THEORETICAL KNOWLEDGE EXAMINATIONS COMPLETED (PPL Holders only) To be completed by the ATO conducting the Training Confirmation of Theoretical Knowledge training course completed: CPL ATP Category of Examinations: Aeroplane Helicopter Airship Theoretical Knowledge training completed on course:... Hours Approved Training Organisation:... ATO Approval No:... Competent Authority issuing Approval:... Name of Head of Training:... Give details of Competent Authority with whom the Examinations were taken:... Certified copied of results to be provided with application and Certified copy of ATO approval Certificate (if training ATO and examinations not subject to SCAA approval) Signature (Head of Training):... Date:... 12. FI PRE-ENTRY FLIGHT TEST To be completed by the ATO conducting the Training I recommended (name)... for the Flight Instructor Course. Date of satisfactory pre-entry flight test:... Name of FI qualified in accordance with FCL.905.FI(i) who conducted flight test (block capitals):... Licence Number:... Competent Authority issuing Licence:... Approved Training Organisation (ATO):... ATO Approval No:... Competent Authority issuing Approval:... Signature (FI who conducted flight test):... Date:... Form SR FCL 1131 Issue 06 Page 4 of 8
13. APPROVED COURSE CERTIFICATE (not required if the ATO provides a Certificate of course completion) To be completed by the ATO conducting the Training I certify that (name)... has satisfactorily completed an approved course of training in accordance with Part-FCL for the following: i) FI (A) FI (H) FI (AS) FI (B) FI (S) ii) Type Rating Instructor TRI(A) (Please specify type):... iii) Type Rating Instructor TRI(H) (Please specify type):... iv) Type Rating Instructor TRI(PL) (Please specify type):... v) TRI issued in accordance with FCL.725(e) (Please specify type):... vi) Class Rating Instructor CRI SE ME SE & ME vii) Instrument Rating Instructor IRI A IRI (H) IRI (AS) viii) Synthetic Flight Instructor SFI (SPA) (MPA) (H) (PL) ix) Multi-Crew Cooperation Instructor MCCI Flight Test Instructor The course consisted of... hours of theoretical knowledge Instruction. If a credit towards the teaching and learning was given in accordance with FCL.915(c)(1) please indicate which Instructor Certificate is held: FI CRI TRI IRI MCCI FSI FTI The course consisted of... hours of flight instruction of which...hours instrument ground time in a FTD 2/3 or FNPT I or FNPT II/III or FSS. FSTD Identification Number of simulator used (which must be issued in accordance with CAD ARA... Competent Authority issuing Qualification certificate for the simulator:... Approved Training Organisation:... ATO Approval No:... Competent Authority issuing Approval:... Name of Head of Training:... Signature (Head of Training):... Date:... 14. CONFIRMATION OF ASSESSMENT OF COMPETENCE To be completed by the Applicant I have successfully completed an Assessment of Competence for the issue of an Instructor Certificate. Assessment of Competence Date(s):... Aircraft Type and Registration:... or FSTD Identification Number:... Examiner s Name:... Examiner s Number:... Note - Applicants are advised that the licence will not be issued until the corresponding Examiner's Report Form is received. Form SR FCL 1131 Issue 06 Page 5 of 8
15. DECLARATION OF APPLICANT (tick as appropriate) To be completed by the Applicant I declare that the information provided on this form is correct. Signature:... Date:... 16. SCAA USE ONLY Date of Issue... Checked by... Loaded by... Signed by... Enclosures 17. SUBMISSION INSTRUCTIONS (See Guidance Notes) Please send your completed application and supporting documentation (see Guidance Notes) to the following address: Personnel Licensing Inspectorate Safety Regulation Seychelles Civil Aviation Authority P.O Box 181 Victoria, Seychelles 18. PAYMENT METHOD Please complete form SR\1187. You may also wish to refer to our Fees Schedule which can be found on our web site at www.scaa.sc under Safety Regulation, then Legislation then Fees Schedule. Form SR FCL 1131 Issue 06 Page 6 of 6
Application for Issue of an Instructor Certificate in Accordance with CAD-FCL (Part-FCL) GUIDANCE NOTES GUIDANCE NOTE 1 and Submission Instructions Having a clear application form and logbook (where appropriate) will enable PLO to issue licences and ratings more efficiently, with less risk of errors or rejections with subsequent delays to your application. Please note that failure to submit a correctly completed application form with the required supporting documents will lead to the formal rejection of your application. In this instance we will issue you with a 30 day notice to meet the outstanding requirements and failure to meet this deadline may result in your application being cancelled. Please send your completed application and supporting documentation (see Guidance Notes) to the following address: Personnel Licensing Office Safety Regulation Seychelles Civil Aviation Authority P.O Box 181 Victoria, Seychelles GUIDANCE NOTE 2: Important Information Please note the following important information for all applications. Application for the issue of an Instructor Certificate to a Seychelles licence will be issued in accordance with Part-FCL. In order to exercise the privileges of a Pilot licence where the operations of the aircraft require the use of radio communications equipment, the individual must hold a valid Flight Radiotelephony Operator's Licence. Such a licence will only be granted if the applicant holds a valid Language Proficiency Certificate in English in accordance with Appendix 2 of Part-FCL.055 prior to licence application. Should you not hold a valid Language Proficiency in English; your application will be returned. It is an offence to make, with intent to deceive, any false representations for the purpose of procuring the grant, issue, renewal or variation of any certificate, licence, approval, permission or other document. Persons doing so render themselves liable and subject to prosecution under the current applicable regulations. GUIDANCE NOTE 3: Certifiers of Documentation The following people can act as 'certifiers': Head of Approved Training Organisation. Instructions for the certifier of your documents are as follows: 1. Insert on the copy to be enclosed with the application: 'I have seen the original document and I certify that this is a complete and accurate copy of the original'. 2. Insert signature and date. 3. Certifier's name must be printed in block capitals. 4. Must include position or capacity, e.g. Head of Approved Training Organisation Form SR FCL 1131 Issue 06 Guidance Notes Page i of ii
GUIDANCE NOTE 4: Application applied for Which sections of the application form to complete Sections to be fully completed FI (A/H/As/B/S) 1, 2, 3, 4, 5, 6, 7, 11, 12, 13, 14, 15, 17. TRI (A/H/PL) 1, 2, 3, 4, 5, 6, 8, 13, 14, 15, 17. CRI 1, 2, 3, 4, 5, 6, 8, 13, 14, 15, 17. IRI (A/H/As) 1, 2, 3, 4, 5, 6, 8, 13, 14, 15, 17. SFI (SPA/MPA/H/PL) 1, 2, 3, 4, 5, 6, 8, 13, 14, 15, 17. MCCI 1, 2, 3, 4, 5, 6, 8, 13, 15, 17. STI (A/H) 1, 2, 3, 4, 5, 6, 9, 10, 15, 17. FTI 1, 2, 3, 4, 5, 6, 8, 13, 15, 17. GUIDANCE NOTE 5: Supporting documentation required with the application Application Original flying logbook(s). Assessment of Competence Examiners Report (Competent Authorities copy of form SRG 2199). Certified copy of the applicants Certificate of Revalidation page from licence. See guidance note 3. Third country ICAO Flight Crew Licence with Instructor Rating and validating Medical Certificate (if applicable). Certified copies of professional flight crew theoretical knowledge examinations results. See guidance note 3. Copy of Part-FCL Examiner's Approval certificate and licence (if Examiner is not approved by SCAA). See guidance note 3. Copy of Part-ORA Approved Training Organisations (ATO) Approval certificate (if ATO is not approved by SCAA). See guidance note 3. FI (A/H/As) FI (B/S) N/A N/A CRI N/A IRI (A/H/As) N/A FTI N/A N/A N/A N/A TRI (A/H/PL) N/A SFI (A/H) N/A N/A STI N/A N/A N/A N/A N/A MCCI N/A N/A N/A N/A Form SR FCL 1131 Issue 06 Guidance Notes Page ii of ii