DIRECTORATE GENERAL OF CIVIL AVIATIONS

DIRECTORATE OF AIRWORTHINESS AND AIRCRAFT OPERATION

Gedung Perkantoran Bandara Soekarno-Hatta Jl. C3, cengkareng, Tangerang Indonesia
Telp.: (62-21) 2256 6288, 2560 8887 Fax.: (62-21) 35066632256 6399
Email: dgca_dac@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:
AFIYA KRYSNA BASHYARI 29 / 01 / 1998 21 M F
PLACE OF BIRTH: ID OR PASSPORT NO.: NATIONALITY:
PEMALANG 3327092901980005 INDONESIA
PERMANENT MAILING ADDRESS: CITY: PROVINCE:
JALAN PIERE TENDEAN RT 005 RW 001 DUSUN PEMALANG CENTRAL JAVA
SARWODADI, CIBELOK, TAMAN, PEMALANG
ZIP CODE:
52361
EMPLOYER OR ORGANIZATION NAME: SEKOLAH TINGGI PENERBANGAN INONESIA

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

 PRACTICAL EXPERIENCE FOR BASIC CERTIFICATE WRITTEN TEST

 AIRCRAFT MAINTENANCE TRAINING ORGANIZATION AMTO NAME: SEKOLAH TINGGI PENERBANGAN INDONESIA
(AMTO) UNDER PART 147 TRAINING WITHOUT
EXAMINING AUTHORITY AMTO NO. : 147D-03
 AOC / AMO NAME: -
AIRCRAFT TYPE TRAINING UNDER PART 91, 121, 135
& 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

WIRA GAUTHAMA, ST., SSiT, MPd

HEAD OF QUALITY CONTROL

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)