AJX Application Form Check List (First Officer)

AJX Application Form Check List (First Officer) Candidate Name (Forename / Surname) / Items Today's Date: Subjects OK YES Memo Apply Date Date of birth If re-applying for the position, note the previous apply date Current / last Company Nationality Domicile Passport 1.Validity 2. Clear copy attachment 1. ICAO ATPL validity 2. ICAO ATPL license clear copy attachment (Frozen ATPL not accepted) Licenses 3. Instrument rating license validity 4. Instrument rating license clear copy 5. Medical (1 st class) validity 6. Medical (1 st class) license clear copy 1.Check if you have one (aircraft types B737/A320 equivalent or bigger commercial jet) Commercial jet aircraft (2 men or more) type rating 2. Name all the types and the valid dates. Flight Time 3.Clear copies of type rating page attachment Total Flight time more than 3000 hrs Commercial Jet time more than 1000 hrs. Jet time on military jet should not be included. Hours Hours Cross country PIC time : Hours (more than 100 hrs) Cross country time : Hours (more than 200 hrs) Instrument flight time : Hours (more than 75 hrs) Night flight time : Hours(more than100 hrs) Total PIC time : Hours (more than 250 hrs) PUS time : FMS Equipped Glass Cockpit Experience B767 type rating #(This is not requisite condition) Check if it is co-pilot type rating or full (no restriction) type rating. Clear copy attachment requested. restriction Co-pilot Clear copy BMI (body mass index) tice term Less than 30 BMI=Weight (kg)/height(m)*height(m) (Pls. Enter BMI to Check column if BMI<29.) BMI = Commuting Location Interview note *Please check candidate ATPL is issued from ICAO country under this web site http://www.icao.int/cgi/statesdb4.pl?en

APPLICATION FORM All information you furnish is treated in confidence and will not be used without your permission. Ensure that your employment record is continuous. If the space allowed for any question is insufficient please use a separate sheet. Please print ( hand writing) SURNAME : FORENAME(S) : If you have name in Chinese/Japanese character, please print. DATE OF BIRTH (DD/MM/YY) : HEIGHT (Centimetres) : WEIGHT (Kilograms) : POSITION APPLYING FOR ; CAPTAIN, F/O PASSPORT DETAILS PASSPORT NO 1 PASSPORT NO 2 COUNTRY COUNTRY DATE OF ISSUE DATE OF ISSUE CONTACT DETAILS PERMANENT ADDRESS TEMPORARY ADDRESS CITY CITY STATE STATE ZIP CODE ZIP CODE COUNTRY COUNTRY TELEPHONE TELEPHONE FAX NO FAX NO MOBILE MOBILE E-MAIL 1 E-MAIL 1 E-MAIL 2 E-MAIL 2 LICENCE ATPL LICENSE 1 (Current Licence) ATPL LICENSE 2 NUMBER NUMBER COMMAND TYPE RATINGS COUNTRY OF ISSUE DATE OF ISSUE INSTRUMENT RATING DATE OF LAST MEDICAL OF MED COMMAND TYPE RATINGS COUNTRY OF ISSUE DATE OF ISSUE INSTRUMENT RATING DATE OF LAST MEDICAL OF MED

EMPLOYMENT HISTORY (If the space allowed is insufficient use a separate sheet)

ADDENDUM

PERIODS OF UNEMPLOYMENT Please account for any periods of unemployment of at least 30 days FROM(MM/YY) TO(MM/YY) REASON INSTRUCTOR QUALIFICATIONS AIRCRAFT TRAINING QUALIFICATIONS (Line/Base/Ground/Sim etc) AIRLINE FLYING EXPERIENCE AIRCRAFT FMS Equipped Glass Cockpit Command Time (P1) TOTAL TIME Co-Pilot Time(P2)* INSTRUCTOR TIME DATE OF LAST FLIGHT (DD/MM/YY) 1. When entering aircraft type please specify aircraft series (e.g. B737-200/B737Efis, B747/B747-400) * 2. Command (P1) time does not include Cruise Captain time or P1u/s time 3. Do not include Simulator time in flight times TOTAL TOTAL JET TIME*: TOTAL B757/B767 TTL P1: JET P1*: JET P2*: TTL P2: INSTRUMENT EFIS: CROSS COUNTRY CROSS COUNTRY PIC NIGHT FLIGHT TIME : *Commercial Jet time only-do not include Helicopter time CURRENCY RECORD TOTAL FLYING HOURS IN LAST 6 MONTHS AIRCRAFT TYPE: P1: P2: DATE OF LAST PROFICIENCY CHECK ;, A/C TYPE ;, RENEWAL ;. DATE OF LAST INSTRUMENT RATING ;, A/C TYPE ;, RENEWAL ;.

ACCIDENTS/INCIDENTS/ATC VIOLATIONS Give details of any A/C accidents, incidents or ATC violations in which you have been involved: BACK GROUND INFORMATION Have you ever been convicted of a criminal offence in a court of law? If yes give details. / (If, give details:) Have you ever been convicted of a violation of any Federal or State Statute for DUI/DWI? / (If, give details:) CURRENT EMPLOYMENT STATUS If you are currently employed, how are you planning to work for AJX? 1. Resign from current position 2. Apply for LOA 3. Currently furloughed 4. Currently unemployed If your answer is 2 or 3, what is the maximum period of time you can apply for? AVAILABILITY FOR EMPLOYMENT / NOTICE TERM When could you start training if offered position? How long is your notice of resignation to current employer? Please answer available date () or notice term. COMMUTING DETAILS If offered position, from which country and city are you planning to commute to Japan? If the above commuting city is outside Asia or Oceania, are you willing to relocate if necessary? If so, where can you relocate? EXPERIENCE OF OTHER AIRLINES APPLICATION Have you ever applied for ANA Group Companies (Air Japan/ANA & JP Express/ANK) previously? YES NO If yes, which company? Air Japan, ANA & JP Express ANK, I underwent screening process in / ( mm / yy ), which was successful / unsuccessful Have you ever applied for Japanese airlines previously? YES NO (i.e. JAL, JALways, JAL express, AirDo, Skymark, &etc) Company name :, I underwent screening process in / ( mm / yy ), which was successful / unsuccessful DECLARATION I certify that this application is true and correct to the best of my knowledge and that if any falsification is found this will be ground for termination of application process or agreement with written notice having immediate effect. Signed :, Date :.

Autobiographical & Other Relevant Information (This section should include further relevant information in regards to your application not covered in the attached application form. This information can cover such topics as; work experience, management experience, explanation for resigning from previous employers, further information on any accidents or incidents, hobbies and interests etc) Applicant Name: / Applying For ; Captain / First Officer

Supplemental Authorization for Release of Records This authorization is provided in connection with a consumer report or investigative consumer report ("background check") that may be conducted by Universal Background Screening, Inc. at the request of Crew Resources Worldwide, LLC. This authorization is a supplement to any previous disclosures, notices and authorizations obtained by Crew Resources Worldwide, LLC in compliance with the Fair Credit Reporting Act (FCRA) and applicable state laws. I,, hereby authorize, any court, law enforcement agency, school, college, university (public or private), employer, or other record-holding agency to furnish any and all background information requested by Universal Background Screening, or another organization acting on behalf of Universal Background Screening, to the extent permitted by law. These records may include, but are not limited to, employment, education, professional licensure or certification, criminal history, civil court records, driving records, and/or any other public records. I agree that a facsimile ("fax"), photographic or electronic copy of this Authorization shall be as valid as the original. Print Name Date FCRA:SUPPLEMENTAL:008823:20140809