Form SRG1411A "Application for the Initial Issue of an Air Traffic Controller (Atco) Licence (Regulation UK (Eu) 2015/340)" - United Kingdom

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Application for the Initial Issue of an Air Traffic Controller (ATCO)
Licence (Regulation UK (EU) 2015/340)
Please complete this form online (preferred method) then print, sign and submit as
instructed. Alternatively, print, then complete in BLOCK CAPITALS using black or dark blue
ink.
Post or scan and email in accordance with Section 8.
Please read attached Guidance Notes before completing this form.
FALSE REPRESENTATION STATEMENT
It is an offence under the UK Air Navigation Order to make, with intent to deceive, any false representation for the purpose
of procuring the grant, issue, renewal or variation of any certificate, licence, approval, permission or other document.
Persons doing so render themselves liable, on summary conviction, to a fine not exceeding the statutory maximum and on
conviction on indictment to an unlimited fine or imprisonment for a term not exceeding two years or both.
1. PERSONAL DETAILS (Complete as shown on passport)
(Completed by the Applicant)
Serial Number of Student Licence:
Title: ………………….
Surname: …………..…….…………...
Forename(s): …………………………………..……………..
Date of Birth (dd/mm/yyyy): ………………….…………………..
Nationality: ……………..………………………..……………
Place of Birth: ………………………………..……….……………
Country of Birth: ……………………..……………………….
Applicants Address:
………………………………………………..………………..………..………………………………….…
………………………………………………..…………………..……..………………………………….…
………………………………………………..…………………………..……………………………………
County: …………………………. Postcode: ………………… Country: …………………..…………..
Telephone Numbers:
Home: ……………………………………………… Mobile: ………………………………………………
Email Address: ……………………………………………………………………………………………….
Unit Name:
……………………………………….………..………………..………..………………………………….…
Unit Address:
……………………………………….………..………………..………..………………………………….…
…………………………………….…………..………………..………..………………………………….…
County: …………………………. Postcode: ………………… Country: …………………..…………..
ICAO Location Indicator:
The licence will be sent to the unit by default unless specified otherwise by the unit or individual with an explanation
to: ats.licensing@caa.co.uk.
2. NOTIFICATION OF UNIT ENDORSEMENT ASSESSMENT
(Completed by the Applicant)
Location of assessment: …………………………………………. Proposed date (dd/mm/yyyy): ………………………………..
3. RATING/ENDORSEMENT TO BE ASSESSED
(Completed by the Applicant)
Unit Endorsement Sector/Position(s) (if appropriate): ………………………………………………………………………………..
Rating
Rating Endorsement
Description
ADV Aerodrome Control Visual:
ADI Aerodrome Control Instrument:
TWR:
Tower Control
AIR:
Air Control
RAD:
Aerodrome Radar
GMC:
Ground Movement Control
GMS:
Ground Movement Surveillance
Form SRG 1411A Issue 03, June 2021
Page 1 of 3
Application for the Initial Issue of an Air Traffic Controller (ATCO)
Licence (Regulation UK (EU) 2015/340)
Please complete this form online (preferred method) then print, sign and submit as
instructed. Alternatively, print, then complete in BLOCK CAPITALS using black or dark blue
ink.
Post or scan and email in accordance with Section 8.
Please read attached Guidance Notes before completing this form.
FALSE REPRESENTATION STATEMENT
It is an offence under the UK Air Navigation Order to make, with intent to deceive, any false representation for the purpose
of procuring the grant, issue, renewal or variation of any certificate, licence, approval, permission or other document.
Persons doing so render themselves liable, on summary conviction, to a fine not exceeding the statutory maximum and on
conviction on indictment to an unlimited fine or imprisonment for a term not exceeding two years or both.
1. PERSONAL DETAILS (Complete as shown on passport)
(Completed by the Applicant)
Serial Number of Student Licence:
Title: ………………….
Surname: …………..…….…………...
Forename(s): …………………………………..……………..
Date of Birth (dd/mm/yyyy): ………………….…………………..
Nationality: ……………..………………………..……………
Place of Birth: ………………………………..……….……………
Country of Birth: ……………………..……………………….
Applicants Address:
………………………………………………..………………..………..………………………………….…
………………………………………………..…………………..……..………………………………….…
………………………………………………..…………………………..……………………………………
County: …………………………. Postcode: ………………… Country: …………………..…………..
Telephone Numbers:
Home: ……………………………………………… Mobile: ………………………………………………
Email Address: ……………………………………………………………………………………………….
Unit Name:
……………………………………….………..………………..………..………………………………….…
Unit Address:
……………………………………….………..………………..………..………………………………….…
…………………………………….…………..………………..………..………………………………….…
County: …………………………. Postcode: ………………… Country: …………………..…………..
ICAO Location Indicator:
The licence will be sent to the unit by default unless specified otherwise by the unit or individual with an explanation
to: ats.licensing@caa.co.uk.
2. NOTIFICATION OF UNIT ENDORSEMENT ASSESSMENT
(Completed by the Applicant)
Location of assessment: …………………………………………. Proposed date (dd/mm/yyyy): ………………………………..
3. RATING/ENDORSEMENT TO BE ASSESSED
(Completed by the Applicant)
Unit Endorsement Sector/Position(s) (if appropriate): ………………………………………………………………………………..
Rating
Rating Endorsement
Description
ADV Aerodrome Control Visual:
ADI Aerodrome Control Instrument:
TWR:
Tower Control
AIR:
Air Control
RAD:
Aerodrome Radar
GMC:
Ground Movement Control
GMS:
Ground Movement Surveillance
Form SRG 1411A Issue 03, June 2021
Page 1 of 3
3. RATING/ENDORSEMENT TO BE ASSESSED (CONTINUED)
(Completed by the Applicant)
APP Approach Control Procedural:
APS Approach Control Surveillance:
SRA:
Surveillance Radar Approach
PAR:
Precision Approach Radar
TCL:
Terminal Control
ACP Area Control Procedure:
OCN:
Oceanic
ACS Area Control Surveillance:
TCL:
Terminal Control
OCN:
Oceanic
4. DETAILS OF APPLICABLE RATING TRAINING COURSE
(Completed by the Applicant)
Rating: ………..……… Approved Course completed (dd/mm/yyyy): ……………….. Course number: …………….………..
Name of training organisation: …………………………………………………………………………………………………………..
5. DECLARATION BY UNIT
(Completed by the Unit Manager)
I, the undersigned, hereby certify that:
The applicant meets the relevant requirements of Commission Regulation (EU) 2015/340.
The applicant is recommended for a Unit Endorsement Assessment.
Date (dd/mm/yyyy): ................................................................... Signature: ...........................................................................
Surname: .................................................................................. Forenames: ........................................................................
Post held: ..................................................................................................................................................................................
6. FINANCIAL DECLARATION
(MUST BE COMPLETED BY APPLICANT EVEN IF PAYMENT IS MADE BY A THIRD PARTY)
I am applying for the initial issue of an Air Traffic Controller (ATCO) Licence.
I hereby declare that to the best of my knowledge the particulars entered on this application are accurate.
I enclose the charges payable on application in accordance with the Scheme of Charges (www.caa.co.uk/ors5).
I agree to pay any additional charges which may become payable in respect of this application under the Scheme of Charges.
Name of Applicant (as shown in 1): ..........................................................................................................................................
Signature of Applicant (named in 1): ....................................................................................... Date: ....................................
7. PAYMENT BY A THIRD PARTY
If payment for this application is not being made by the applicant, this form must be countersigned by the payee.
I, (name) ……………………………………………………………. authorise the Civil Aviation Authority to use the details given
on the attached payment authorisation (FCS1500) in support of this application.
Signature of Payer: ................................................................................................................... Date: ....................................
Address: ....................................................................................................................................................................................
Contact Telephone Number: ......................................................
Form SRG 1411A Issue 03, June 2021
Page 2 of 3
8. SUBMISSION INSTRUCTIONS
Please check:
• All Sections relevant to the application have been completed;
• The declaration has been signed by the applicant and the Unit Manager; and
• The correct remittance is included with the application (refer to Section 7 Guidance Notes);
when completed, return to:
Civil Aviation Authority
Aviation House
Beehive Ring Road
Crawley
West Sussex
RH6 0YR
or e-mail to:
ats.licensing@caa.co.uk
Telephone Enquiries: +44 (0)330 022 1972
Form SRG 1411A Issue 03, June 2021
Page 3 of 3
Application for the Initial Issue of an Air Traffic Controller (ATCO)
Licence
Guidance on completion of CAA Form SRG 1411A
General
This form is used by the holder of a Student ATCO Licence to apply for an ATCO licence.
Section 1
Personal Details
To maintain consistency of personal detail records please ensure the details entered match that on the applicant’s passport.
The Applicants Permanent Address must be the applying ATCO’s address not the unit’s address.
Fully complete the Unit Address and ICAO Locator Indicator code.
Section 2
Notification of Unit Endorsement Assessment
Enter the proposed date (see below) and the location of the assessment.
The Unit Endorsement assessment board for the initial issue of an ATCO’s licence must always be chaired by a CAA
Inspector ATS. Please contact your CAA Regional Office Inspector ATS to agree a date for the assessment before submitting
this form.
To allow time for processing, this form should be submitted at least 15 days before the agreed assessment date.
CAA ATS Licensing will issue an ATCO licence on receipt of this form. The licence will contain the details of the
Rating/Endorsement being assessed including the expiry date, based on the proposed assessment date. Should, for any
reason, the proposed assessment date have to be amended, notify ATS Licensing by e mail (ats.licensing@caa.co.uk) of
the new date as soon as possible. ATS Licensing will issue a new licence based on the new assessment date. The old
licence is to be returned to the CAA at the address shown in section 8.
Should the unit endorsement assessment be cancelled inform ATS licensing and your CAA Regional Office.
NOTE: COMPLETION OF A UNIT ENDORSEMENT ASSESSMENT MUST BE NOTIFIED TO THE CAA ON FORM
SRG1411D
Section 3
Rating/Endorsement to be Assessed
Tick the appropriate boxes to indicate the Rating and Rating Endorsement, where relevant, to be assessed and enter details
of Sector/Position against the Rating Endorsement if appropriate.
Section 4
Details of Rating Training Course
This section must be completed with the Initial Training Organisation Rating course details relevant to the assessment.
Section 5
Declaration by Unit
Must be completed by the ATS Unit manager or other senior staff member.
Section 6
Financial Declaration
This must be completed by the applicant.
Section 7
Payment
Certain Air Traffic Service Providers/Training Organisations e.g. NATS, have an ‘Agreed Method of Payment’ with the CAA
that does not require them to complete the Payment Authorisation form FCS1500.
All other organisations must make the appropriate payment by any of the methods shown on form
FCS1500
and send
completed form FCS1500 with the application.
Form SRG 1411A Issue 03, June 2021 Guidance Notes
Page i of ii
SRG Forms for ATCO Licensing
• SRG1411A:
Application for the Issue of an Air Traffic Controller Licence
• SRG1411B:
Application for the inclusion, renewal or cancellation of Unit Endorsements in an ATCO Licence
• SRG1411D:
Notification of Completion of an Air Traffic Controller (ATCO) Unit Endorsement Assessment
• SRG1411E:
Application for the Notification of a Change to Personal Details to an ATCO or FISO licence or Radio
Operator Certificate of Competence
• SRG1411F:
Application for the Issue of a UK Air Traffic Controller (ATCO) Licence by Holders of an EU Member
State Licence issued in accordance with Regulation (EU) 2015/340
• On-Line Form:
Replace a licence or certificate that has been lost, damaged or stolen
• SRG1415:
Application for the issue, revalidation or renewal of an ATC Assessor, OJTI or STDI licence endorsement
• SRG1416:
Record of Revalidation of an ATCO Unit Endorsement
• SRG1421:
Application for the Issue of a Student Air Traffic Controller License or the inclusion of Additional Ratings
• SRG1426:
Air Traffic Controller Licence - Revalidation or Renewal of an English Language Proficiency
Endorsement
Form SRG 1411A Issue 03, June 2021 Guidance Notes
Page ii of ii
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