Form 1317 "Air Traffic Controller Licence" - Kuwait

Form 1317 is a Kuwait Aviation Safety Department form also known as the "Air Traffic Controller Licence". The latest edition of the form was released in April 28, 2016 and is available for digital filing.

Download an up-to-date Form 1317 in PDF-format down below or look it up on the Kuwait Aviation Safety Department Forms website.

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P.O. Box 17, Safat 13001, Kuwait
State of Kuwait
Tel. (965) 2474-3940
Fax (965) 2476-5796
Directorate General of Civil Aviation
SITA: KWIASYA
Email: safety@dgca.gov.kw
Aviation Safety Department
Air Traffic Controller Licence
Notes: i)
Read the form thoroughly and complete the appropriate sections only.
ii) Complete the form in BLOCK CAPITALS or tick boxes
unless otherwise indicated
SECTION 1) APPLICATION FOR
(Complete Sections Listed)
Grant of an Air Traffic Controller Licence, Rating, Rating Endorsement, Unit Endorsement or English Language
Proficiency Endorsement (Sections 1, 2, 3, 4, 5, 7 and 8)
Air Traffic Controller Licence – expiry or withdrawal of an Unit Endorsement (Sections 1, 2, 6 and 7)
Change of Personal Details (Sections 1, 2 and 7)
SECTION 2) PERSONAL DETAILS
ATC Licence Number (if held)
Male
Female
Title:
………………………………
Surname: .....................................................................................
Forename(s)
...................................................................................
Date of Birth (dd/mm/yyyy): .........................................................
Nationality
.......................................................................................
Place of Birth: ..............................................................................
Country of Birth:
............................................................................
Permanent Address:
...........................................................................................................................................................................
...........................................................................................................................................................................
............................................................................................................................................................................
Country: ............................................. Postcode:..................................
Postal Address:
...........................................................................................................................................................................
(normally unit address)
...........................................................................................................................................................................
..........................................................................................................................................................................
Country: ............................................. Postcode:..................................
Telephone Numbers:
Home:
................................................................................................................................................................
(incl. area code)
Office:
................................................................................................................................................................
SECTION 3) UNIT ENDORSEMENT APPLIED FOR:
Proposed date (dd/mm/yyyy): …………………………………….
Location of examination: .....................................................................
Note: This information MUST be included
Unit Endorsement
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 No: 1317
Page 1 of 4
28 April 2016 v0.1
P.O. Box 17, Safat 13001, Kuwait
State of Kuwait
Tel. (965) 2474-3940
Fax (965) 2476-5796
Directorate General of Civil Aviation
SITA: KWIASYA
Email: safety@dgca.gov.kw
Aviation Safety Department
Air Traffic Controller Licence
Notes: i)
Read the form thoroughly and complete the appropriate sections only.
ii) Complete the form in BLOCK CAPITALS or tick boxes
unless otherwise indicated
SECTION 1) APPLICATION FOR
(Complete Sections Listed)
Grant of an Air Traffic Controller Licence, Rating, Rating Endorsement, Unit Endorsement or English Language
Proficiency Endorsement (Sections 1, 2, 3, 4, 5, 7 and 8)
Air Traffic Controller Licence – expiry or withdrawal of an Unit Endorsement (Sections 1, 2, 6 and 7)
Change of Personal Details (Sections 1, 2 and 7)
SECTION 2) PERSONAL DETAILS
ATC Licence Number (if held)
Male
Female
Title:
………………………………
Surname: .....................................................................................
Forename(s)
...................................................................................
Date of Birth (dd/mm/yyyy): .........................................................
Nationality
.......................................................................................
Place of Birth: ..............................................................................
Country of Birth:
............................................................................
Permanent Address:
...........................................................................................................................................................................
...........................................................................................................................................................................
............................................................................................................................................................................
Country: ............................................. Postcode:..................................
Postal Address:
...........................................................................................................................................................................
(normally unit address)
...........................................................................................................................................................................
..........................................................................................................................................................................
Country: ............................................. Postcode:..................................
Telephone Numbers:
Home:
................................................................................................................................................................
(incl. area code)
Office:
................................................................................................................................................................
SECTION 3) UNIT ENDORSEMENT APPLIED FOR:
Proposed date (dd/mm/yyyy): …………………………………….
Location of examination: .....................................................................
Note: This information MUST be included
Unit Endorsement
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 No: 1317
Page 1 of 4
28 April 2016 v0.1
P.O. Box 17, Safat 13001, Kuwait
State of Kuwait
Tel. (965) 2474-3940
Fax (965) 2476-5796
Directorate General of Civil Aviation
SITA: KWIASYA
Email: safety@dgca.gov.kw
Aviation Safety Department
APP Approach Control Procedural
*Sector/Position(s) (if appropriate)
APS Approach Control Surveillance
RAD
Radar
.....................................................
SRA
Surveillance Radar Approach
.....................................................
PAR
Precision Approach Radar
.....................................................
TCL
Terminal Control
.....................................................
OFF
Offshore
.....................................................
SPT
Special Tasks
SECTION 3) UNIT ENDORSEMENT APPLIED FOR:
ACP Area Control Procedure
*Sector/Position(s) (if appropriate)
ACS Area Control Surveillance
RAD
Radar
.....................................................
TCL
Terminal Control
.....................................................
OFF
Offshore
FOR THE RATING APPLIED FOR, PROVIDE DETAILS OF THE APPROVED COURSE COMPLETED
Rating: ....................................
Approved Course completed (dd/mm/yyyy): ..................................... Course number: .......................
Name of training organisation:....................................................................................................................................................................
Rating: ....................................
Approved Course completed (dd/mm/yyyy): ..................................... Course number: .......................
Name of training organisation:....................................................................................................................................................................
Rating: ....................................
Approved Course completed (dd/mm/yyyy): ..................................... Course number: .......................
Name of training organisation:....................................................................................................................................................................
SECTION 4) UNIT ENDORSEMENT EXAMINATION RESULTS (enter results after Examination is complete)
Actual examination date (dd/mm/yyyy): ...................................................................................................................................................
State the Unit Endorsement (from the table above)
Practical
Oral
………………………………………………………………………..
PASS
FAIL
PASS
FAIL
………………………………………………………………………..
………………………………………………………………………..
PASS
FAIL
PASS
FAIL
………………………………………………………………………..
………………………………………………………………………..
PASS
FAIL
PASS
FAIL
………………………………………………………………………..
………………………………………………………………………..
PASS
FAIL
PASS
FAIL
Examination remarks (where the outcome is ‘FAIL’, Examiners are to record reasons for the decision)
Practical:
Oral:
MEMBERS OF THE EXAMINATION BOARD (including supernumerary Examiners if present)
Surname .................................................................................
Forename(s) .............................................................................
Examiner Licence number: ........................................
Chair
Supernumerary
Signature: ...............................................
Form No: 1317
Page 2 of 4
28 April 2016 v0.1
P.O. Box 17, Safat 13001, Kuwait
State of Kuwait
Tel. (965) 2474-3940
Fax (965) 2476-5796
Directorate General of Civil Aviation
SITA: KWIASYA
Email: safety@dgca.gov.kw
Aviation Safety Department
Surname .................................................................................
Forename(s) .............................................................................
Examiner Licence number: ........................................
Chair
Supernumerary
Signature: ...............................................
Surname .................................................................................
Forename(s) .............................................................................
Examiner Licence number: ........................................
Chair
Supernumerary
Signature: ...............................................
Where an examination was not completed on the dates planned, please tick the appropriate box and return to ASD at the address on
page 4.
Unit Endorsement Exam postponed – alternative date to be arranged with ASD and new form DGCA/ATS/503 to be submitted
Unit Endorsement Exam cancelled – no alternative date will be arranged
Signed .............................................................................................
SECTION 5) ENGLISH LANAGUAGE PROFICIENCY ENDORSEMENT
This section is to be completed for the initial award of the English Language Proficiency Endorsement.
The English Language Proficiency of the applicant has been assessed in accordance with Unit procedures.
The applicant has been assessed against the ICAO language proficiency rating scale and has been assessed to have proficiency in the
English Language at the following level (delete as applicable):
Level 6 (Expert Level)
Level 5 (Extended Level)
Level 4 (Operational Level)
The assessment was carried out on (dd/mm/yyyy): ..................................................................................................................................
Assessment conducted by
Surname: .....................................................................................
Forename(s): ...................................................................................
Examiner Licence Number: .........................................................
Signature: ........................................................................................
SECTION 6) CANCELLATION OF UNIT ENDORSEMENT
(Complete only if Unit Endorsement has expired or been withdrawn)
Rating/Rating Endorsement/Sector/Operational Position (e.g. ADI/TWR/RAD/GMS/XXXX Tower) Date expired/withdrawn (dd/mm/yyyy)
……………………………………………………………………………………………………………… ……………………………………………
……………………………………………………………………………………………………………… ……………………………………………
False Statement
The making of false statement for the purpose of procuring the issue of a certificate of registration is an offence under the Act 60 of
1960. The Directorate General of Civil Aviation may, in any case in which they think it is desirable, require the applicant for a certificate
of registration to furnish such evidence as they may desire and to make and subscribe a statutory declaration as to the truth of the
facts set out in the application.
SECTION 7) DECLARATION BY APPLICANT
I hereby declare that I have carefully considered the statements made and that to the best of my belief they are correct.
Signature: ........................................................................................................................
Date (dd/mm/yyyy): ...................................
DECLARATION BY TRAINING ORGANISATION/AERODROME AUTHORITY/ATC CENTRE AUTHORITY
Form No: 1317
Page 3 of 4
28 April 2016 v0.1
P.O. Box 17, Safat 13001, Kuwait
State of Kuwait
Tel. (965) 2474-3940
Fax (965) 2476-5796
Directorate General of Civil Aviation
SITA: KWIASYA
Email: safety@dgca.gov.kw
Aviation Safety Department
I, the undersigned, hereby certify (delete as appropriate):
The details of the air traffic control training are correct and/or that the Unit Training Plan requirements have been satisfactorily
completed.
The applicant is recommended for Unit Endorsement(s).
The applicant no longer holds the Unit Endorsement(s) stated in Section 6.
Date (dd/mm/yyyy): ...........................................................
Signature: ..................................................................................................
Surname: ...........................................................................
Forenames: ................................................................................................
Training Organisation/Aerodrome/ATC Centre Authority:............................................................................................................................
Postal Address:
...........................................................................................................................................................................
.........................................................................................................................................................................
..........................................................................................................................................................................
Country: ............................................. Postcode:..................................
Delivery Instructions
This form, when completed, should be forwarded and must be accompanied by the appropriate fee to;
Directorate General of Civil Aviation, Aviation Safety Department, P.O. Box 17, Safat 13001, State of Kuwait
Note 1: The DGCA/ASD requires a minimum of 2 weeks to process a completed application.
Note 2: Refer to Kuwait Civil Aviation Safety Regulations 27 for charges and fees.
Payment Instructions
Cheque, Demand Draft etc. made payable in favour of DIRECTORATE GENERAL OF CIVIL AVIATION, or Telex
Transfer directly to our Account at;
CENTRAL BANK OF KUWAIT, P. O. BOX: 526, SAFAT, 13006, KUWAIT.
ACCOUNT NO. 42/4170
For official use only (DGCA/ASD)
Date of Receipt:
Enclosures Checked by
Name:
Office:
Application
Accepted:
Rejected:
Pending:
Approved:
Remarks:
Name and signature of authorised staff member
Name:
Signature:
Date:
Form No: 1317
Page 4 of 4
28 April 2016 v0.1
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