MINISTRY OF TRANSPORTATION

DIRECTORATE GENERAL OF CIVIL AVIATION

Office Complex Soekarno-Hatta International Airport, C3 St., Tangerang, Banten- Indonesia
Telp.: (+6221) 225 66288, (+6221) 256 08887 Fax. : (+6221) 225 66399
Website : hubud.dephub.go.id; e-mail: daao_dgca@dephub.go.id

APPLICATION FOR WRITTEN TEST

I. CERTIFICATE APPLICATION
BASIC CERTIFICATE : TYPE RATING:

 A1 - AIRFRAME,  A3 - PISTON  C1 - RADIO  CATEGORY A :

AIRPLANE ENGINES
 C4 - ELECTRICAL
 A2 - AIRFRAME,  A4 - TURBINE  CATEGORY C :
HELICOPTER ENGINES
 C2 - INSTRUMENT

II. APPLICANT INFORMATION

NAME: DATE OF BIRTH: AGE: SEX:
/ / M F
PLACE OF BIRTH: ID OR PASSPORT NO.: NATIONALITY:

PERMANENT MAILING ADDRESS: CITY: PROVINCE:

ZIP CODE:

EMPLOYER OR ORGANIZATION NAME:

III. BASIC CERTIFICATE, LICENSE OR CATEGORY APPLIED FOR ON BASIS OF:

 PRACTICAL EXPERIENCE FOR BASIC CERTIFICATE WRITTEN TEST

 AIRCRAFT MAINTENANCE TRAINING ORGANIZATION AMTO NAME:

(AMTO) UNDER PART 147 TRAINING WITHOUT
EXAMINING AUTHORITY AMTO NO. :

 AIRCRAFT TYPE TRAINING UNDER PART 91, 121, 135

AOC / AMO NAME:
& 145. AOC / AMO NO. :

IV. RECORD OF PRACTICAL EXPERIENCE

(LIST PRACTICAL EXPERIENCE FOR BASIC CERTIFICATE WRITTEN TEST)
DATES: MONTH & YEAR
EMPLOYER TYPE OF WORK PERFORMED
FROM TO

V. APPLICANT’S CERTIFICATION
I CERTIFY THAT THE STATEMENTS MADE BY ME ON THIS APPLICATION ARE TRUE
EMPLOYEE EMPLOYER
DATE SIGNATURE NAME & TITLE SIGNATURE

DGCA Form No. 65-01 (Oct 2017)

 VI. DGCA INSPECTOR EVALUATION TASK
SUBJECT SAT UNSAT N/A
REQUIRED DOCUMENTS
1. Application Letter   
2. Copy of Certificate of Aircraft Type Training   
3. Copy of Graduation Certificate   
4. Statement of Competency   
5. Copy of National ID or Passport   

ELIGIBILITY & EXPERIENCE

1. Eligibility Requirement   
2. Experience Requirement   

REMARK:

I HAVE EXAMINED THE THE APPLICATION LETTER AND EVALUATED THE ELIBILITY & EXPERIENCE
OF APPLICANT
RESULT DATE SIGNATURE / STAMP

 APPROVED
FOR WRITTEN TEST:

 REJECTED

DGCA Form No. 65-01 (Oct 2017)