APPLICATION FOR STUDENT AIR TRAFFIC CONTROLLER’S LICENCE I. APPLICATION INFORMATION STUDENT LICENCE □ A. Full Name (First, Middle, Last) B. Date of Birth of Birth D. Nationality (dd-mm-yy) E. Sex F. Height G. Weight H. Hair colour I. Eye colour Male Female (Inches) (Lbs) □ □ J. Address & Contact numbers: Telephone: Facsimile: e-mail: & contact numbers: K. Employer’s name, address Telephone: Facsimile: e-mail: L. Do you hold a current Medical Certificate? Yes No □ □ M. Issuing Authority: N. Class of Certificate O. Date of Issue (dd.mm.yy) Bermuda Civil Aviation Authority II. STUDENT LICENCE APPLIED FOR ON BASIS OF TRAINING AT A BCAA APPROVED INSTITUTION: a. Name of training institution: b. Successful completion of training and examinations: YES □ c. Date of letter or certificate of completion from BCAA approved institution: III. THE FOLLOWING DOCUMENTS MUST BE ENCLOSED WITH THIS APPLICATION: a Valid Medical Certificate. □ b. Copy of letter or certificate of completion from BCAA approved institution. □ c. Two (2) passport size photographs of applicant. □ IV. CERTIFICATION: I certify that the above information is true and correct to the best of my knowledge. It is an offence to make, with the intent to deceive, any false representation for the purpose of procuring the grant, issue, renewal, or variation of a licence. Any person so doing renders himself liable, on summary conviction, to a fine not exceeding £400 (or equivalent) or on conviction on indictment to a fine or imprisonment for term not exceeding two years or both. Signature of Applicant………………………………………. Date………………………………. Form ATC 02 (08/16)
APPLICATION FOR STUDENT AIR TRAFFIC CONTROLLER’S LICENCE I. APPLICATION INFORMATION STUDENT LICENCE □ A. Full Name (First, Middle, Last) B. Date of Birth (dd-mm-yy) of Birth D. Nationality E. Sex Male □ Female □ F. Height (Inches) G. Weight (Lbs) H. Hair colour I. Eye colour J. Address & Contact numbers: Telephone: Facsimile: e-mail: K. Employer’s name, address & contact numbers: Telephone: Facsimile: e-mail: L. Do you hold a current Medical Certificate? Yes □ No □ M. Issuing Authority: Bermuda Civil Aviation Authority N. Class of Certificate O. Date of Issue (dd.mm.yy) II. STUDENT LICENCE APPLIED FOR ON BASIS OF TRAINING AT A BCAA APPROVED INSTITUTION: a. Name of training institution: b. Successful completion of training and examinations: YES □ c. Date of letter or certificate of completion from BCAA approved institution: III. THE FOLLOWING DOCUMENTS MUST BE ENCLOSED WITH THIS APPLICATION: a □ Valid Medical Certificate. b. □ Copy of letter or certificate of completion from BCAA approved institution. c. □ Two (2) passport size photographs of applicant. IV. CERTIFICATION: I certify that the above information is true and correct to the best of my knowledge. It is an offence to make, with the intent to deceive, any false representation for the purpose of procuring the grant, issue, renewal, or variation of a licence. Any person so doing renders himself liable, on summary conviction, to a fine not exceeding £400 (or equivalent) or on conviction on indictment to a fine or imprisonment for term not exceeding two years or both. Signature of Applicant………………………………………. Date………………………………. Form ATC 02 (08/16)
FORM-LC-ATC02-StudentATC.docx