Form SRG1421 "Application for the Issue of a Student Air Traffic Controller (Atco) Licence or the Inclusion of Additional Ratings to Student and Atco Licences (Regulation UK (Eu) 2015/340)" - United Kingdom

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Application for the Issue of a Student Air Traffic Controller (ATCO)
Licence or the Inclusion of Additional Ratings to Student and
ATCO Licences (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 7.
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. APPLICATION FOR
(Completed Sections Listed)
Issue of a new Student Air Traffic Controller Licence (Sections 2, 3, 5 and 6)
Inclusion of an Additional Rating on a Student Air Traffic Controller Licence (Sections 2, 4, 5 and 6)
Inclusion of an Additional Rating on an Air Traffic Controllers Licence (Sections 2, 4, 5 and 6)
When applying for the issue of a Student Air Traffic Controller’s licence a certified copy of your valid Passport,
EEA/EU National Identity Card or Full EU Photographic Driving Licence (see Guidance Note 1) must accompany
your application as proof of identification.
2. PERSONAL DETAILS (Complete as shown on passport)
(Completed by the Applicant)
Serial Number of Licence (if known):
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.
3. ISSUE OF A STUDENT AIR TRAFFIC CONTROLLERS LICENCE
Please provide details of the CAA approved ATC rating training course completed:
Rating: .................................................. Name of training organisation: ..................................................................................
Approved Course completed on (dd/mm/yyyy): .............................. Course reference: ..........................................................
English Language Proficiency level awarded (in accordance with the ICAO Language Proficiency Rating Scale):
(Please tick as appropriate and enclose a copy of the English Language Proficiency certificate issued by the ATC training
organisation)
Level 6
Level 5
Level 4
Form SRG 1421 Issue 09, June 2021
Page 1 of 2
Application for the Issue of a Student Air Traffic Controller (ATCO)
Licence or the Inclusion of Additional Ratings to Student and
ATCO Licences (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 7.
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. APPLICATION FOR
(Completed Sections Listed)
Issue of a new Student Air Traffic Controller Licence (Sections 2, 3, 5 and 6)
Inclusion of an Additional Rating on a Student Air Traffic Controller Licence (Sections 2, 4, 5 and 6)
Inclusion of an Additional Rating on an Air Traffic Controllers Licence (Sections 2, 4, 5 and 6)
When applying for the issue of a Student Air Traffic Controller’s licence a certified copy of your valid Passport,
EEA/EU National Identity Card or Full EU Photographic Driving Licence (see Guidance Note 1) must accompany
your application as proof of identification.
2. PERSONAL DETAILS (Complete as shown on passport)
(Completed by the Applicant)
Serial Number of Licence (if known):
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.
3. ISSUE OF A STUDENT AIR TRAFFIC CONTROLLERS LICENCE
Please provide details of the CAA approved ATC rating training course completed:
Rating: .................................................. Name of training organisation: ..................................................................................
Approved Course completed on (dd/mm/yyyy): .............................. Course reference: ..........................................................
English Language Proficiency level awarded (in accordance with the ICAO Language Proficiency Rating Scale):
(Please tick as appropriate and enclose a copy of the English Language Proficiency certificate issued by the ATC training
organisation)
Level 6
Level 5
Level 4
Form SRG 1421 Issue 09, June 2021
Page 1 of 2
4. ADDITIONAL RATING(S) TO BE INCLUDED ON LICENCE
Please provide details of the CAA approved ATC rating training course completed:
Rating 1: ............................................... Name of training organisation: ..................................................................................
Approved Course completed on (dd/mm/yyyy): .............................. Course reference: ..........................................................
Rating 2: ............................................... Name of training organisation: ..................................................................................
Approved Course completed on (dd/mm/yyyy): .............................. Course reference: ..........................................................
5. FINANCIAL DECLARATION
(MUST BE COMPLETED BY APPLICANT EVEN IF PAYMENT IS MADE BY A THIRD PARTY)
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 2): ..........................................................................................................................................
Signature of Applicant (named in 2): ....................................................................................... Date: ....................................
6. 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: ......................................................
7. SUBMISSION INSTRUCTIONS
Please check:
• Section 2 (Personal Details) has been fully completed;
• All Sections relevant to the application have been completed;
• The declaration has been signed by the applicant;
• A copy of the English Language Proficiency certificate is enclosed, where required (refer to Section 3); and
• The correct remittance is included with the application (refer to Section 6 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 1421 Issue 09, June 2021
Page 2 of 2
Application for the Issue of a Student Air Traffic Controller (ATCO)
Licence or the Inclusion of Additional Ratings to Student and
ATCO Licences
Guidance on completion of CAA Form SRG1421
General
This form is used for the following:
To obtain a Student Air Traffic Controllers Licence
To and add additional ratings to a Student Air Traffic Controllers Licence
To add additional ratings to an Air Traffic Controller’s Licence
Section 1
Tick the appropriate box and complete the sections indicated.
Section 2
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 3
Issue of a Student Air Traffic Controllers Licence
Enter details of the rating training course completed and the training organisation.
This section must also include the English Language proficiency Level achieved.
Section 4
Inclusion of an Additional Rating to an Air Traffic Controller’s Licence or a Student Air Traffic
Controller’s licence
Tick the appropriate boxes to indicate if the additional rating applies to an Air Traffic Controller’s Licence or a Student Air
Traffic Controller’s licence.
Enter details of the rating training course completed and the training organisation.
There are currently no charges associated with the inclusion of additional ratings.
NOTE: Where the application is for the addition of new ratings a new licence containing the new and existing ratings
will be issued. On receipt of this licence the applicant is to return their old licence to the address shown in Section
7.
Section 5
Financial Declaration
This must be completed by the applicant even if payment is being made by a third party or where no payment is required.
Section 6
Payment
To be completed if the payment is being made by a third party.
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 1421 Issue 09, June 2021 Guidance Notes
Page i of ii
GUIDANCE NOTE 1: Certifiers of ID
Certified ID is only required for the issue of a Student Air Traffic Controllers Licence.
The following people can act as 'certifiers:
Any senior staff member of the approved training organisation where training has been undertaken.
Any Senior Staff member of the applicant’s employer.
Instructions for the certifier of your ID document are as follows:
1. Insert on the copy to be enclosed with the application: 'I have seen the original document and I certify that this is a
complete and accurate copy of the original'.
2. Insert signature and date.
3. Certifier’s name must be printed in block capitals.
4. Must include position or capacity, e.g. Training College Assessor.
Note: For those individuals who do not hold the accepted forms of identity, the CAA will on a case by case basis accept
alternative documents. As a rule, the document must have at least a photograph and full name plus one other identifying
feature i.e. date of birth, address etc. of the applicant.
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 1421 Issue 09, June 2021 Guidance Notes
Page ii of ii
Page of 4