VI. DGCA INSPECTOR EVALUATION TASK ‘SUBJECT SAT USAT We REQUIRED DOCUMENTS 1. “Application Letter a Q a 2. Copy of Certificate of Aircraft Type Training o a a 3. Copy of Graduation Certificate Qa o a 4, Statement of Competency a a a 5. Copy of National ID or Passport a o a ELIGIBILITY & EXPERIENCE 1. Eligibility Requirement 2. Experience Requirement oo oo oo REMARK: THAVE EXAMINED THE THE APPLICATION LETTER AND EVALUATED THE ELIBILITY & EXPERIENCE OF APPLICANT RESULT DATE ‘SIGNATURE / STAMP, QAPPROVED FOR WRITTEN TEST: QREJECTED GCA Form No. 65-01 (Oct 2017)MINISTRY OF TRANSPORTATION DIRECTORATE GENERAL OF CIVIL AVIATION Office Complex Soekamo-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_dgcar@dephub go.id APPLICATION FOR WRITTEN TEST |. CERTIFICATE APPLICATION BASIC CERTIFICATE TYPE RATING WAT ARFRAME, OAS-PISTON Ter=RADIS TGATEGORYA ‘AIRPLANE ENGINES c4- ELECTRICAL QA2-AIRFRAME, OYAd- TURBINE TICATEGORY © HELICOPTER ENGINES ¢9_STRUMENT Il, APPLICANT INFORMATION NAME: DATE OF BRT: AGE ox Davip Guva WiGawa 22, 1, 1994 24 |omy oF PLACE OF BRT 1D OR PASSPORT NO NATIONALITY “TANCERANG, 560406 2211970004 INDONESIA ERIN ENG ADDRESS or PROVINCE Teal Et/ew S/o, or KEES faANGERaNn ketsek q Qanten Kee. Kescer, Kan. TanberanG TECE 4BCLO EMPLOYER OR ORGANIZATION NAME> Ill, BASIC CERTIFICATE, LICENSE OR CATEGORY APPLIED FOR ON BASIS OF: G | PRACTICAL EXPERIENCE FOR BASIC CERTIFICATE WRITTEN TEST (GY | ARCRAFT MAINTENANCE TRAINING ORGANIZATION | AMTO NAME: StkobaH Tce) TERNDLOGI KepRGanTanaarl (ANTO) UNDER PART 147 TRAINING WITHOUT EXAMINING AUTHORITY ANTONO, Ywto-14 TAMO NAN OF | pipcRart TYPE TRAINING UNDER PART, 121,135 [AOC . as. ‘AOC / AMO NO. IV. RECORD OF PRACTICAL EXPERIENCE (LIST PRACTICAL EXPERIENCE FOR BASIC CERTIFICATE WRITTEN TEST) DATES: MONTH & YEAR ERou 70 EMPLOYER TYPE OF WORK PERFORMED V. APPLICANT'S CERTIFICATION I CERTIFY THAT THE STATEMENTS MADE BY ME ON THIS APPLICATION ARE TRUE EMPLOYEE, EMPLOYER, DATE ‘SIGNATURE NAME & TITLE, SIGNATURE. 01 NovemBER 2021 ie DGCA Form No, 65-01 (Oct 2017)