Form SRG1411D "Notification of Completion of an Air Traffic Controller (Atco) Unit Endorsement Assessment" - United Kingdom

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Notification of Completion of an Air Traffic Controller (ATCO) Unit
Endorsement Assessment (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 5.
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 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. TYPE OF UNIT ENDORSEMENT ASSESSED
(Completed by the Applicant)
Initial Issue:
New Rating/Subsequent Issue:
Renewal:
Temporary (Special Event):
3. UNIT ENDORSEMENT ASSESSMENT RESULTS
(Completed by Assessor)
Actual Assessment Date (dd/mm/yyyy): ….…….…… Temporary Endorsement Expiry Date (if applic.) (dd/mm/yyyy): ……….……
Unit Endorsement details: (Sector / Rating / Rating Endorsement)
Practical
Oral
PASS
FAIL
PASS
FAIL
……………………………………………………………………………….
PASS
FAIL
PASS
FAIL
……………………………………………………………………………….
PASS
FAIL
PASS
FAIL
……………………………………………………………………………….
PASS
FAIL
PASS
FAIL
……………………………………………………………………………….
Form SRG 1411D Issue 03, June 2021
Page 1 of 2
Notification of Completion of an Air Traffic Controller (ATCO) Unit
Endorsement Assessment (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 5.
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 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. TYPE OF UNIT ENDORSEMENT ASSESSED
(Completed by the Applicant)
Initial Issue:
New Rating/Subsequent Issue:
Renewal:
Temporary (Special Event):
3. UNIT ENDORSEMENT ASSESSMENT RESULTS
(Completed by Assessor)
Actual Assessment Date (dd/mm/yyyy): ….…….…… Temporary Endorsement Expiry Date (if applic.) (dd/mm/yyyy): ……….……
Unit Endorsement details: (Sector / Rating / Rating Endorsement)
Practical
Oral
PASS
FAIL
PASS
FAIL
……………………………………………………………………………….
PASS
FAIL
PASS
FAIL
……………………………………………………………………………….
PASS
FAIL
PASS
FAIL
……………………………………………………………………………….
PASS
FAIL
PASS
FAIL
……………………………………………………………………………….
Form SRG 1411D Issue 03, June 2021
Page 1 of 2
Assessment remarks (where the outcome is ‘FAIL’, Assessors are to record reasons for the decision):
Practical:
Oral:
4. MEMBERS OF THE ASSESSMENT BOARD
(Completed by Assessor(s))
Surname: …………………………………………………….. Forename(s): ………………………………………………………….
Assessor Licence number:
Chair:
Assessor:
Signature: ……………………………….
Surname: …………………………………………………….. Forename(s): ………………………………………………………….
Assessor Licence number:
Chair:
Assessor:
Signature: ……………………………….
Surname: …………………………………………………….. Forename(s): ………………………………………………………….
Assessor Licence number:
Chair:
Assessor:
Signature: ……………………………….
5. SUBMISSION INSTRUCTIONS
Please check:
• Section 1 (Personal Details) has been fully completed;
• All Sections relevant to the application have been completed;
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 1411D Issue 03, June 2021
Page 2 of 2
Notification of Completion of an Air Traffic Controller (ATCO) Unit
Endorsement Assessment
Guidance on completion of CAA Form SRG 1411D
General
This form must be used to notify CAA Licensing Assessment of the completion of a Unit Endorsement Assessment. This
form must be used to notify the completion of Unit Endorsement Assessments relating to:
• The Initial Issue of an ATCO Licence (SRG 1411A)
• The Issue of a new or subsequent Rating/Rating Endorsement to an existing licence (SRG 1411B)
• The Renewal of an ATCO Unit Endorsement (SRG 1411B)
• The Issue of a Temporary Unit Endorsement for a Special Event (SRG 1411B)
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
Type of Unit Endorsement Assessed
Be sure to tick the correct box relating to the type of assessment carried.
Initial Issue, New rating or Subsequent issue, Renewal, Temporary, Exchange.
Section 3
Rating/Endorsement to be Assessed
This section is to be completed by the Assessor.
Enter the date of the assessment and for a Temporary Unit Endorsement (Special Event) the expiry date.
Enter the Unit Endorsement details i.e. the Rating and rating endorsement, if applicable, including sector/position as
appropriate and indicate ‘Pass’ or ‘Fail’ as applicable.
If a ‘Fail’ is indicated enter reasons in space provided.
Section 4
Members of the Assessment Board
Enter Assessors details and signatures.
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 1411D Issue 03, June 2021 Guidance Notes
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