BELGIAN CIVIL AVIATION AUTHORITY
EUROPEAN UNION
Date of reception:
Application for registration as NON-Belgian Examiner
False representation statement
Any incorrect information could disqualify the applicant from taking any examination or being granted a
personnel licence, certificate, rating, authorisation or attestation.
According to regulation EC 1178/2011 holders of an examiner certificate shall not conduct skill tests, proficiency checks or assessments of
competence of an applicant for which the competent authority is not the same that issued the examiner’s certificate, unless:
(1) they have informed the competent authority of the applicant of their intention to conduct the skill test, proficiency check or
assessment of competence and of the scope of their privileges as examiners;
(2) they have received a briefing from the competent authority of the applicant on a briefing on the national administrative
procedures, requirements for protection of personal data, liability, accident insurance and fees.
1. Applicant details
Title:
to be completed by the applicant
Forename(s):
Surname:
Date of birth (dd/mm/yyyy):
Nationality:
Town of birth:
Country of birth:
Permanent address:
Postcode:
Telephone:
Alternative telephone number:
E-mail:
Fax number:
2. Address for correspondence (if different from above)
to be completed by the applicant
Postal address:
Postcode:
3. Statement of briefing completion
to be completed by the applicant
I hereby declare I have read and understood those parts of the ”BRIEFING FOR NON-BELGIAN FLIGHT
EXAMINERS AIRPLANE & HELICOPTER – initial issue – april 2013”.
I declare that the information provided on this form is correct.
Name of the examiner:
Signature:
Date:
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LA/L-PEL/0107D52E – FCL.Subpart K
Vers:
0.1 Issued :
01/04/2013
4. Application
to be completed by the applicant
I am applying for:
Flight examiner
FE(A)
FE(H)
FE(B)
FE(As)
FE(S)
Type rating examiner TRE(A) (please specify type):
Type rating examiner TRE(H) (please specify type):
Type rating examiner TRE(PL) (please specify type):
Class rating examiner CRE(A)
Instrument rating examiner
IRE (A)
IRE (H)
IRE (As)
Synthetic flight examiner
SFE (A)
SFE (H)
SFE (PL)
Flight instructor examiner
FIE(A)
FIE(H)
FIE(B)
FIE(As)
FIE(S)
I added following supporting documents:
Copy of examiner certificate
Copy of medical certificate
Copy of pilot licence
CAA use only
5. CAA use only
I hereby authorise Mr/Mrs:
with License number:
to conduct skill tests, proficiency checks and assessments of competence for a Belgian PART-FCL or
JAR-FCL licence, and
to endorse, in compliance with FCL 1030 (b) (2) the applicant’s licence or certificate with the new expiry
date of the rating or certificate.
Note 1: Acceptability of an examiner to test Belgian-licensed pilots is dependent upon the examiner’s certificate
issued by the examiner’s State of Licence Issue remaining valid in compliance with the requirements of
Part-FCL and Part-ARA under the oversight of the examiner’s competent authority.
Note 2: Each test (skill, proficiency, assessment of Competence) must be registered 24 hours before the test.
Note 3: An examiner shall before taking an initial skill test(ST) or initial Assessment of Competence (AC)
obtain the approval from the BCAA.
Authorisation number: BE/
Remarks:
Date of issue:
Expiry date:
Signed by:
Note: this application form and supporting documents must be scanned and send to the following
email address: [email protected]
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LA/L-PEL/0107D51E – FCL.Subpart K
Vers:
0.1 Issued :
01/04/2013