驾驶员执照及等级申请表

FS-CH-61R4-2（11/2014）
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III 基于下列哪一项目申请执照和等级 License or Rating Applied for on Basis of □A 按 61 部完成训练 和考试 Completion of Training and Test according to CCAR-61 25 完成训练的单位名称 Name of Flight Training Unit 26 地址 Location 28 机 构 名 称 Name of Flight Training School or Training Center 27 完成日期 Date of Graduate 年Y 月M 日D 29 合格证编号 Certificate No. 合格证种类 Type of certificate □B 毕业于按 141 部或 142 部批准的训练课程 Graduate of an Approved CCAR-141 or CCAR-142 Training Course □CCAR-141 30 地址 Location 31 完成的课程名称 Curriculum from Which Graduated 32 该课程是否具有实践考试权 Does the practice examination rights issued to the syllabus? □是，继续填写 V 项 Yes, Fill in the V □否，继续填写 IV 项 No, Fill in the IV 34 服务单位 □C 国家航空器驾驶员 National Competence Obtained in □D 持有境外驾驶员执 照 Holder of Pilot License issued by other Authority □E 完成经批准航空承 运人训练大纲 Completion of Air Carrier's Approved Training Program 33 完成日期 Date of Graduate 年Y 月M 日D □CCAR-142
声明：我保证上述填写内容属实，如有不实后果本人负责。 APPLICANT'S STATEMENT: I certify that all statements and answers provided by me on the application form are complete and true to the best of my knowledge. 44 申请人签字 Signature of Applicant 45 申请日期 Date of Application 年Y 月M 日D
考试员报告 Designated Examiner's Report 50 地面 Ground 考试时间 Duration of Test 51 模 拟 机 或 训 练 器 52 飞行 Flight Simulator/FTD
53 被考执照或等级 License or Rating for Which Tested
54 使用的航空器 Type of Aircraft
55 航空器登记号 Registration No.
56 考试员合格证编号 Certificate No.
57 委任期满日期 Designation Expires 年Y 月M 日D
58□我审查了申请人驾驶员飞行经历记录本或训练记录及以下文件，证实其满足 CCAR-61 部有关所申请执照或等级的 要求。 I have personally reviewed this applicant's pilot logbook, training record and following documents, and certify that the individual meets the pertinent requirements of CCAR-61 for the license or rating sought. □驾驶员执照 Pilot License □飞行经历记录本 Logbook □身份证明 Identification Document □体检合格证 Medical Certificate □训练课程合格证明 Graduation Certificate for Training Course □学历证明 Education Certificate □理论考试成绩单 Passing Grade for Airman Knowledge Test □不通过通知书 Notice of Not Pass of Application □不批准通知书 Notice of Disapproval of Application □其它 Others ________________________________________ □我依据有关程序和标准对申请人进行了实践考试（附工作单） ，结论如下。 I have personally tested and/or verified this applicant in accordance with pertinent procedures and standards with the result indicated below. □通过 Passed □不通过并填写《不批准通知书》 Failed □其它 Others 59 考试员签字 Signature 考试日期 Date of Test 年Y 月M 日D
照 片 Photo (蓝底彩色小 2 寸) Small 2 inch blue background
5 出生地 Place of Birth 8 通讯地址 Mailing Address
6 民族(中国籍)Chinese Only
10 工作单位 Service Organization
12 身份证明名称 Type of Identification Document 13 身份证明编号 Identification Document No. □身份证 ID □其它 Others 14 学习简历 起止年月 Period 校、院、专业及取得的学位 School, College, Major and Degree Education
民用航空器驾驶员执照和等级申请表
Application for Civil Aircraft Pilot License and/or Rating
用墨水笔或打印填写所有项目 Type or Print All Entries in Ink
I 基本信息 Basic Information 1 姓名(汉语及全拼)Name 2 国籍 Nationality 3 出生日期 Date of Birth 年Y 月M 日D 4 性别 Sex □男 Male □女 Female 7 联系电话 Telephone 9 邮政编码 Zip Code 11 永久住址 Permanent Residence Address
35 获得的最高天气标准
36a 过去 24 个月内在_______________国家航空器上担任机长时间_______小时 36b 过去 12 个月内在_______________国家航空器上担任机长时间_______小时 37 国 家 或 地 区 Country or Region 40 所持等级 Ratings 41a 航空承运人名称 Name of Air Carrier 41b 合格证种类 Type of certificate □CCAR-121 42 完成课程 Which Curriculum □初始 Initial □升级 Upgrade □转机型 Transition □CCAR-135 43 完成日期 Date of Completion 年Y 月M 日D 38 执照种类 Grade of License 39 执照编号 License Number
申请人身份证明名称 Type of Identification Document □身明编号 Identification Document No.
IV 授权教员推荐 我对该申请人进行了飞行教学，认为其已具备参加所申请执照和等级实践考试的条件。 INSTRUCTOR'S RECOMMENDATION: I have personally instructed the applicant and consider this person ready to take the practical test.
15 工作经历 Experience
起止年月 Period
在何地、何部门、任何职务 Location, Service Organization and Title
II 申请信息 Application Information 16 是否持有或曾经持有过 17a 执照编号 License No. 18 颁发日期 Date of Issue CAAC 颁发的驾驶员执照？ 年Y 月M 日D 17b FN 编号 FN Serial Number Do you hold a CAAC Pilot License? 执照到期日期 Date of Expiration □是 Yes □否 No 年Y 月M 日D 19 持有 CAAC 颁发的有效的体检合格证等级 □I □II □III □IV 20 体检合格证有效期至__年___月___日 Which class of the valid CAAC Medical Certificate do you hold? Date of Expiration Y M D 21 你能正确读、听、说、写汉语吗？Can you read, hear, speak and write the Chinese language? □是 Yes □否 No 22 已持有哪国 ICAO 英语语言能力等级签注 Which level and which County of ICAO English Proficiency Level do you hold? □是 Yes 颁发国 Country 等级 Level □无 No 23 是否有处罚记录？Whether you have a record of Penalty? □无 No □有 Yes □行政处罚 Administrative Penalty □警告 Warn □罚款 Fine □暂扣 Suspension □吊销 Revocation 处罚日期 Date of Penalty_____________________ □刑事处罚 Criminal Penalty 处罚日期 Date of Penalty_________________ 说明 Explanation_______________________________________________________________ 24a 申请执照或等级 Application Information □初次申请 Initial Application □增加等级 Additional Rating □执照更新 Renewal 24b 申请执照或等级 Application Information □运动驾驶员执照 Sports Pilot License 填写附件 1 Fill in attachment 1 □私用驾驶员执照 Private Pilot License 填写附件 2 Fill in attachment 2 □商用驾驶员执照 Commercial Pilot License 填写附件 3 Fill in attachment 3 □多人制机组驾驶员执照 Multi-Crew Pilot License 填写附件 4 Fill in attachment 4 □航线运输驾驶员执照 Airline Transport Pilot License 填写附件 5 Fill in attachment 5 □仪表等级 Instrument Rating 填写附件 6 Fill in attachment 6 □型别等级 Type Rating 填写附件 4 Fill in attachment 4 □基础教员等级 Flight Instructor Rating 填写附件 7 Fill in attachment 7 □仪表教员等级 Flight Instructor-Instrument Rating 填写附件 8 Fill in attachment 8 □型别教员等级 Type Rating Instructor Rating 填写附件 9 Fill in attachment 9 □运动教员等级 Sport Instructor Rating 填写附件 10 Fill in attachment 10 声明：我保证上述填写内容属实，如有不实后果本人负责。 APPLICANT'S STATEMENT: I certify that all statements and answers provided by me on the application form are complete and true to the best of my knowledge. 申请人签字 Signature of Applicant