I. Demande de /(Application for): A. Délivrance Initiale Original Issuance B. Qualifications / Rating. Qualification Additionnelle Added Rating

Transcription

1 FORMULAIRE DE DEMANDE : LICENCE DE TECHNICIEN DE MAINTENANCE D AERONEFS (TMA), QUALIFICATION, CONVERSION OU VALIDATION Aviation Maintenance Technician Licence, Rating, Conversion or Validation Certificate Application I. Demande de /(Application for): A. Délivrance Initiale Original Issuance B. Qualifications / Rating Renouvellement Renewal Réémission Reissue Qualification Additionnelle Added Rating Validation Validation Conversion Conversion Cellule / Airframe Motopropulseur / Powerplant Avionique / Avionics Autre / Other II. Informations sur le Candidat / Applicant Information 1. Nom complet / Legal name (last, first, middle) 2. Numéro Passeport/Carte d identité / Identification number (e.g. driver s licence, passport) 3. Date de naissance / Date of birth (dd/mm/yyyy) 4a. Adresse Permanente / Permanent mailing address (number and street) 4b. Ville et Etat / Province (City and state/province) 4c. Pays et code Postal / (Country and postal code) 5. Lieu de Naissance (ville, Etat / province, Pays) / Place of birth (city, state / province, country) 6. Numéro de téléphone / Telephone number 7. Courriel / address 8. Nationalité / Nationality Page 1 sur 1 MXL-01 / ANAC BENIN

2 9. Taille / Height (cm) 10. Poids / Weight (kg) 11. Genre / Gender 12. Cheveux / Hair 13. Yeux / Eyes Homme / Male Femme / Female 14a. Détenez-vous présentement ou avez vous détenu une licence béninoise? Si oui, complétez les blocks 14b au 14e / Do you now hold, or have you ever held, a Benenese CAA licence? If yes, complete blocks 14b through 14e. OUI / Yes NON/ No 14b.Si oui, votre licence a t-elle jamais été suspendue ou révoquée? / If yes, has your licence ever been suspended or revoked? OUI / Yes Date NON / No 14c. Type de licence / Type of licence 14d. Numéro de la licence / Licence number 14e. Date de délivrance / Date issued (dd/mm/yyyy) 15a. Comprenez-vous et parlez-vous couramment le Français? / Do you speak and understand the language of Benenese? OUI / Yes NON / No 15b. Parlez-vous et comprenez-vous l anglais? Do you speak and understand the English language? OUI / Yes NON / No Page 2 sur 2 MXL-01 / ANAC BENIN

3 III. Demande de Licence, de Qualifications, de Conversions ou de validation faite sur la base de : / Licence, Rating, Conversion or Validation Certificate Applied for on the Basis of: A. Test de Connaissance Théorique / Knowledge Test 1. Candidature à un Test de Connaissance de : / Knowledge test applied for 2a. Test de connaissance théorique réussi pour : / Knowledge test successfully completed for 2b. Test de connaisance théorique réussi le : / Knowledge test date of completion (dd/mm/yyyy) B. Test Pratique / Skill Test 1. Aéronef à utiliser (si examen en vol requis) : / Aircraft to be used (if flight test required) 2. Nombre d heures de vol effectuées dans ce type avion : / Total time in this aircraft 3. Total des Heures de vol en qualité de Commandant de bord sur ce type avion : / Pilot-in-command time in this aircraft C. Elève pilote dans un organisme de formation aéronautique agréé par l ANAC (ATO) / Graduate of an Approved Training Organisation (ATO) 1. Nom de l Organisme de Formation Aéronautique agréé et adresse (ville, Etat / Province, Pays) / ATO name and location (city, state/province, country) 2. Numéro d agrément de l Organisme de Formation Aéronautique / ATO certificate number 3. Intitulé de la formation suivie / Course from which graduated 4. Date de fin de formation / Graduation date (dd/mm/yyyy) D. Détenteur d une licence étrangère / Holder of a Foreign Licence 1. Pays / Country 2. Type de licence / Type of licence 3. Numéro de la licence / Licence number 4. Qualifications / Ratings E. Compétences Militaire / Military Competence 1. Service / Service 2. Date de Qualification / Date rated (dd/mm/yyyy) 3. Echelon ou grade et Numéro de Service / Rank or grade and service number Page 3 sur 3 MXL-01 / ANAC BENIN

4 F. Expérience Civile / Civilian Experience Agence Nationale de l Aviation Civile du Bénin formulaire de demande : licence de technicien de maintenance d aéronefs (TMA), qualification, conversion ou validation IV. Expérience : / Experience 1. Dates / Dates (month and year) 2. Employeur et Emplacement / Employer and Location 3. Types de Travaux effectués / Type of Work Performed De / From A / To V. Attestation du Candidat / Applicant s Certification Je certifie sur l honneur que les informations fournies dans ce formulaire sont exactes / I certify that the statements made by me on this application are true. 1. Signature (Nom et Signature) (print name and sign) 2. Date (jj/mm/aaaa) / (dd/mm/yyyy) Page 4 sur 4 MXL-01 / ANAC BENIN

5 VI. Recommandation en vue du test de connaissances théorique / Endorsement for the Knowledge Test A. instructeur approuvé par l ANAC / Authorised Instructor J ai personnellement instruit le candidat dans les sujets requis par les RABs pour la licence, les qualifications ou le certificat et je considère que ce candidat est prêt à passer le test de connaissance théorique. (I have personally instructed the applicant in the subject areas required by the RAB for the licence, rating, or certificate and consider this person ready to take the knowledge test). 1. Date (jj/mm/aaaa) Date (dd/mm/yyyy) 2. Nom de l instructeur et signature Instructor s name and signature (print name and sign) 3. Numéro de Licence de l instructeur / Instructor s licence number 4. Date d expiration de la licence de l instructeur (jj/mm/aaaa) / Instructor s licence expiration date (dd/mm/yyyy) B. Organisme de Formation agréé / Approved Training Organisation Le candidat à achevé avec succès notre cours intitulé et est recommandé au test de connaissance théorique (The applicant has successfully completed our approved course, and is endorsed for the test). 1. Date (jj/mm/aaaa) (dd/mm/yyyy) 2. Nom de l OFA / ATO name 3. Numéro d agrément de l OFA / ATO certificate number 4. Nom, Titre et Signature du directeur de l OFA. Name, title and signature of ATO official (print name, title and sign) C. Autorisation de l ANAC / CAA Authorisation 1. J ai personnellement revu la demande du candidat, son identité et autres documents exigés dans le cadre de la présente demande et j atteste que cette demande est conforme aux exigences du RAB 01 et ses procédures associées relatives à la licence, qualification ou certificat demandé et l autorise à passer le test de connaissance théorique demandé. I have reviewed this person s application, identification and other required documentation and find this applicant meets the requirements of the RAB for the licence, rating or certificate sought and authorise the applicant to take the knowledge test. Test de connaissance initial / Initial knowledge test Reprise de test de connaissance / Re-take of passing test Reprise de test après échec / Re-test after failure 2. J ai personnellement revu la demande du candidat, son identité et autres documents exigés dans le cadre de la présente demande et j atteste que cette demande n est pas conforme aux exigences du RAB 01 et ses procédures associées relatives à la licence, qualification ou certificat demandé et ne l autorise pas à passer le test de connaissance théorique demandé. I have reviewed this person s application, identification and other required documentation and find this applicant does not meet the requirements of the RAB for the licence, rating or certificate sought and is not authorised to take the knowledge test. 3. Remarques (si applicable) Remarks (if any) 4. Nom, Titre et signature de l inspecteur ANAC qui a effectué la revue de la présente demande / Name, title and signature of the CAA official who conducted the review Nom et Titre (printed name and title) (signature) Date (jj/mm/aaaa) (dd/mm/yyyy) / /. Page 5 sur 5 MXL-01 / ANAC BENIN

6 VII. Recommandation en vue du test pratique / Endorsement for the Skill Test A. instructeur approuvé par l ANAC / Authorised Instructor J ai personnellement instruit le candidat dans les sujets requis par les RABs pour la licence, les qualifications ou le certificat et je considère que ce candidat est prêt à passer le test pratique. (I have personally instructed the applicant in the subject areas required by the RAB for the licence, rating, or certificate and consider this person ready to take the Skill test). 1. Date (jj/mm/aaaa) Date (dd/mm/yyyy) 2. Nom de l instructeur et signature Instructor s name and signature (print name and sign) 3. Numéro de Licence de l instructeur / Instructor s licence number 4. Date d expiration de la licence de l instructeur (jj/mm/aaaa) / Instructor s licence expiration date (dd/mm/yyyy) B. Organisme de Formation agréé / Approved Training Organisation Le candidat à achevé avec succès notre cours intitulé et est recommandé au test pratique (The applicant has successfully completed our approved course, and is endorsed for the test). 1. Date (jj/mm/aaaa) (dd/mm/yyyy) 2. Nom de l OFA / ATO name 3. Numéro d agrément de l OFA / ATO certificate number 4. Nom, Titre et Signature du directeur de l OFA. Name, title and signature of ATO official (print name, title and sign) C. Autorisation de l ANAC / CAA Authorisation 1. J ai personnellement revu la demande du candidat, son identité et autres documents exigés dans le cadre de la présente demande et j atteste que cette demande est conforme aux exigences du RAB 01 et ses procédures associées relatives à la licence, qualification ou certificat demandé et l autorise à passer le test pratique demandé. I have reviewed this person s application, identification and other required documentation and find this applicant meets the requirements of the RAB for the licence, rating or certificate sought and authorise the applicant to take the skill test. Test pratique initial / Initial skill test Reprise de test après échec / Re-test after failure Renouvellement / Renewal Réémission / Re-issue 2. J ai personnellement revu la demande du candidat, son identité et autres documents exigés dans le cadre de la présente demande et j atteste que cette demande n est pas conforme aux exigences du RAB 01 et ses procédures associées relatives à la licence, qualification ou certificat demandé et ne l autorise pas à passer le test pratique demandé. I have reviewed this person s application, identification and other required documentation and find this applicant does not meet the requirements of the RAB for the licence, rating or certificate sought and is not authorised to take the skill test. 3. Remarques (si applicable) Remarks (if any) 4. Nom, Titre et signature de l inspecteur ANAC qui a effectué la revue de la présente demande / Name, title and signature of the CAA official who conducted the review Nom et Titre (printed name and title) (signature) Date (jj/mm/aaaa) (dd/mm/yyyy) / /. Page 6 sur 6 MXL-01 / ANAC BENIN

7 VIII. Résultats des Epreuves Pratiques de Technicien de Maintenance d Aéronefs (TMA)/ Mechanic Skill Test Results 1. Test de Compétences d ordre Général / General Skill Test Remarques / Remarks 1a. Oral Admis / Pass Valable j usqu au / Expiration date Echec / Fail Numéros des questions échouées / Question 1b. Pratique / Practical Admis / Pass Valable j usqu au / Expiration date Echec / Fail Numéros des tâches mal exécutées / Task 2. Test de Compétences Qualification "CELLULE" / Airframe Rating Skill Test Remarques / Remarks Structure "CELLULE" / Airframe Structure 2a. Oral Admis / Pass Valable j usqu au / Expiration date Echec / Fail Numéros des questions échouées / Question 2b. Pratique / Practical Admis / Pass Valable j usqu au / Expiration date Echec / Fail Numéros des tâches mal exécutées / Task Systèmes et Composants "CELLULE" / Airframe Systems and components 2c. Oral Admis / Pass Valable j usqu au / Expiration date Echec / Fail Numéros des questions échouées / Question 2d. Pratique / Practical Admis / Pass Valable j usqu au / Expiration date Echec / Fail Numéros des tâches mal exécutées / Task 3. Test de Compétences Qualification "MOTOPROPULSEUR" / Powerplant Rating Skill Test Remarques / Remarks Théorie et Maintenance "MOTOPROPULSEUR" / Powerplant Theory and Maintenance 3a. Oral Admis / Pass Valable j usqu au / Expiration date Echec / Fail Numéros des questions échouées / Question 3b. Pratique / Practical Admis / Pass Valable j usqu au / Expiration date Echec / Fail Page 7 sur 7 MXL-01 / ANAC BENIN

8 Numéros des tâches mal exécutées / Task Agence Nationale de l Aviation Civile du Bénin formulaire de demande : licence de technicien de maintenance d aéronefs (TMA), qualification, conversion ou validation Systèmes et Composants "MOTOPROPULSEUR" / Powerplant Systems and components 3c. Oral Admis / Pass Valable j usqu au / Expiration date Echec / Fail Numéros des questions échouées / Question 3d. Pratique / Practical Admis / Pass Valable j usqu au / Expiration date Echec / Fail Numéros des tâches mal exécutées / Task 4. Test de Compétences Qualification "AVIONIQUE" / Avionics Rating Skill Test Remarques / Remarks 4a. Oral Admis / Pass Valable j usqu au / Expiration date Echec / Fail Numéros des questions échouées / Question 4b. Pratique / Practical Admis / Pass Valable j usqu au / Expiration date Echec / Fail Numéros des tâches mal exécutées / Task Page 8 sur 8 MXL-01 / ANAC BENIN

9 IX. Compte-rendu de test pratique (Examinateur ou Inspecteur ANAC) / Skill Test Report (Examiner or CAA Inspector) 1. Attestation de l Examinateur ou de l Inspecteur / Examiner or inspector statement a. J ai personnellement revu les informations et le dossier de formation du candidat et j atteste qu il (elle) répond aux exigences pertinentes du RAB 01 et procédures associées pour la licence, la qualification, ou le certificat demandé. / I have personally reviewed this applicant s information and training record, and certify that the individual meets the pertinent requirements of the RAB for the licence, rating or certificate sought. b. J ai personnellement testé / contrôlé ce candidat, conformément aux procédures et exigences pertinentes en vigueur avec les résultats ci-après / I have personally tested/checked this applicant in accordance with pertinent procedures and requirements with the results indicated below. Admis / Approved Echec lettre de refus établie (Original joint) / Disapproved notice of denial issued (original attached) c. J ai personnellement évalué ce candidat, et atteste qu il répond aux exigences de compétences linguistiques pour : / I have personally checked that this applicant meets the language proficiency requirements for the: Français / French Anglais / English language 2. Lieu du Test (Centre, ville, Etat ou province, Pays) Location of test (facility, city, state or province, country) 3. Licence, Qualification ou certificat objet du test / Licence, rating or certificate for which tested 4. Pièces Jointes / Attachments Rapport du Test de Connaissance Théorique / Report of Knowledge Test Certificat Expiré / Superseded certificate Lettre / Letter 5. Date (jj/mm/aaaa) / (dd/mm/yyyy) 6. Nom de l Examinateur ou de l inspecteur et signature / Examiner s or inspector s name and signature (print name and sign) 7. Numéro d examinateur désigné ou numéro de la licence de l inspecteur / Examiner s designation number or inspector s licence number 8. Date d expiration de la désignation de l examinateur / Examiner s designation expiration date (dd/mm/yyyy) Page 9 sur 9 MXL-01 / ANAC BENIN

10 X. Rapport de l ANAC / CAA Report A. Décision de l ANAC / CAA Action Agence Nationale de l Aviation Civile du Bénin formulaire de demande : licence de technicien de maintenance d aéronefs (TMA), qualification, conversion ou validation B. Pièces Jointes / Attachments Recommandation de l Examinateur ou inspecteur / Examiner/Inspector recommendation Admis / Accepted Rejeté (Echec) / Rejected Délivrance de la licence de Technicien de Maintenance d Aéronefs / Issue of licence Renouvellement de la licence de Technicien de Maintenance d Aéronefs / Renewal of licence Réémission de la licence de Technicien de Maintenance d Aéronefs / Re-issue of licence Délivrance de la Qualification / Issue of rating Renouvellement de la Qualification / Renewal of rating Réémission de Qualification / Re-issue of rating Rapport de Test de connaissance théorique / Knowledge test report Rapport de test pratique / Skill test report Lettre de rejet (refus) / Notice of denial Lettre d interruption / Letter of discontinuance Certificat Diplôme (copie) / Graduation certificate (copy) Copie de la carte d identité ou du passeport / Copy of applicant s identification Vérification de l authenticité de la licence étrangère / Verification of authenticity of foreign licence Indiquer la Qualification / Indicate Rating Cellule / Airframe Motopropulseur / Powerplant Avionique / Avionics Délivrance du certificat de validation / Issue of validation certificate Autre / Other C. Identification du candidat / Applicant s Identification Type d identification officielle fournie / Type of government-issued identification Numéro du document d identification / Identification number Date d expiration / Expiration date D. Autorisation de l ANAC / CAA Authorisation 1. la documentation exigée comme pièce jointe est présente et la licence, qualification ou certificat recherché peut être émis / Application documentation is in order and the licence, rating or certificate may be issued. des documents exigés sont manquants et la demande est retournée au candidat / Application is missing the following documentation and will be returned to the applicant. Documents Manquants / Missing documentation 2. Nom, Titre et signature de l inspecteur ANAC qui a effectué la revue / Name, title and signature of the CAA official who conducted the review Nom et Titre (printed name and title) (signature) Date (jj/mm/aaaa) (dd/mm/yyyy) / /. Page 10 sur 10 MXL-01 / ANAC BENIN

11 XI. Délivrance ANAC / CAA Issuance A. Licence, Qualification ou certificat délivré / Licence, Rating or Validation Certificate Issued Licence Expiration date* Qualification / Rating(s) Expiration date* Certificat de validation / Validation certificate Expiration date* * Date format (jj/mm/aaaa) / (dd/mm/yyyy) B. Autorisation de l ANAC / CAA Authorisation Nom, Titre et signature de l officiel ayant formalisé la délivrance / Name, title and signature of CAA official who completed the issuance (printed name and title) (signature) Date (jj/mm/aaaa) (dd/mm/yyyy) Page 11 sur 11 MXL-01 / ANAC BENIN

12 INSTRUCTIONS POUR REMPLIR LE FORMULAIRE / INSTRUCTIONS FOR COMPLETION OF FORM MP-L01 Block 14d. Licence number. Enter the licence number as it appears on your licence. I. Application for: Block 14e. Date issued. Enter the date your licence as issued. Block 15a. Do you speak and understand the language of Benin (national language)? Check yes or no. Block 15b. Do you speak and understand the English language? Check yes or no. Block A.The applicant must check the appropriate box. Original Issuance First (direct) issuance of a grade licence. ene al ene al of the licence ithin the validity period of the licence. eissue eissue of the licence after the licence validity period has expired. Adding ating Adding a rating to an existing licence. alidation equest for a validation certificate to be issued on the basis of a foreign licence. Check the box and proceed to Section II, Applicant Information. Conversion equest to convert a licence based on a foreign licence. Check the box and proceed to Section II, Applicant Information. Block B.The applicant for the direct issuance of a rating must check the appropriate box for the rating being sought. II. Applicant Information Block 1. Legal name. Enter your legal name. Do not change the name on subsequent applications unless it is officially indicated to the authority that the name is changed accompanied by a copy of the marriage licence, court order or other document verifying the name change. Block 2. Identification number. Enter the identification number from the driver s licence, passport or other government issued identification (as specified by the CAA). Block 3. Date of birth. Enter the date of birth as eight digits (dd/mm/yyyy). Use numeric characters, for example, 20/10/1983, instead of 20 October Block 4a. Permanent mailing address (number and street). Enter the residence number and street name of your permanent address. CAA policy requires that you use your permanent mailing address. Justification must be provided on a separate sheet of paper signed and submitted ith the application hen a PO Box or rural route number is used in place of your permanent physical address. A map or directions must be provided if a physical address is unavailable. Block 4b. City & state or province. Enter the city of your permanent address and the state or province as applicable. Block 4c. Country & postal code. Enter the country and postal code of your permanent address. Block 5. Place of birth. Enter the city of birth and the state or province as applicable. Enter the country here you ere born. Block 6. Telephone number. Enter your telephone number. Block 7. address. Enter your address. If you do not have an address, enter None or N/A. Block 8. Nationality. Indicate your nationality from your passport. If you have more than one nationality, indicate so. Block 9. Height. Enter your height in centimetres. Do not enter fractions. Use hole centimetres only. Block 10. Weight. Enter your eight in kilograms. Do not enter fractions. Use hole kilograms only. Block 11. Gender. Check male or female. Block 12. Hair. Enter the colour of your hair. If bald, enter bald. Colour should be listed as black, red, bro n, blonde or gray. Block 13. Eyes. Enter the colour of your eyes. The colour should be listed as blue, bro n, black, hazel, green or gray. Block 14a. Do you no hold, or have you ever held, a Benin CAA licence? Check yes or no. If yes, complete blocks 14b through 14e, other ise proceed to block 15a. Block 14b. If yes, has your licence ever been suspended or revoked? Check yes or no and, if yes, indicate the date. Block 14c. Type of licence. Enter the type of licence you hold or have held. III. Licence, ating, Conversion or alidation Certificate Applied for on the Basis of: Block A. Kno ledge Test 1. Kno ledge test applied for.indicate hich kno ledge test the applicant is applying to take (if applicable). 2a. Kno ledge test successfully completed for. Enter the type of kno ledge test the applicant has completed (if applicable). 2b. Kno ledge test date of completion. Enter the date the kno ledge test as completed as eight digits (dd/mm/yyyy). Use numeric characters, for example, 20/10/1983, instead of 20 October Block B. Skill Test 1. Skill test applied for.indicate hich skill test the applicant is applying to take (if applicable). 2a. Skill test successfully completed for. Enter the type of skill test the applicant has completed (if applicable). 2b. Skill test date of completion. Enter the date the skill test as completed as eight digits (dd/mm/yyyy). Use numeric characters, for example, 20/10/1983, instead of 20 October Block C. Graduate of an Approved Training Organisation (ATO) 1. ATO name and location. Enter the name and location of the approved training organisation (ATO) as sho n on the graduation certificate. Be sure to include the city, state or province as applicable, and country. 2. ATO certificate number. Enter the ATO certificate number as sho n on the graduation certificate. 3. Course from hich graduated. Enter the name of the course from hich you graduated as sho n on the graduation certificate. 4. Graduation date. Enter the date of graduation from the course indicated as eight digits (dd/mm/yyyy). Use numeric characters, for example, 20/10/1983, instead of 20 October Block D. Holder of a Foreign Licence 1. Country. Enter the country hich issued the licence. 2. Type of licence. Enter the type of licence issued. 3. Licence number. Enter the licence number as it appears on your licence. 4. atings. Enter all ratings that appear on the licence. Block E. Military Competence 1. Service. Enter your branch of service. 2. Date rated. Enter the date you graduated from your military training as eight digits (dd/mm/yyyy). Use numeric characters, for example, 20/10/1983, instead of 20 October ank or grade and service number. Enter your rank or grade and service number. Block F. Civilian Experience. List all of your civilian experience in Section I Experience. I. Experience If all of the applicant's experience cannot be recorded in Section I, the applicant may use additional sheets of paper. Block 1. Dates. List the month and year for all of your ork experience as six digits (mm/yyyy). Use numeric characters, for example, 10/1983, instead of October If experience as gained at various locations, use a separate entry to reflect such experience. Block 2. Employer and Location Enter the employer's name and location in this area. Block 3. Type of Work Performed Enter the type of ork performed.. Applicant s Certification Page 12 sur 12 MXL-01 / ANAC BENIN

13 Block 1. Signature. Print and sign your name. Block 2. Date. Enter the date you sign the application as eight digits (dd/mm/yyyy). Use numeric characters, for example, 20/10/1983, instead of 20 October I. Endorsement for the Kno ledge Test Block A. Authorised Instructor 1. Date. Enter the date you sign the application as eight digits (dd/mm/yyyy). Use numeric characters, for example, 20/10/1983, instead of 20 October Instructor s name and signature. Authorised instructor should print and sign name. 3. Instructor s licence number. Enter the instructor s licence number. 4. Instructor s licence expiration date. Enter the expiration date of the instructor licence as eight digits (dd/mm/yyyy). Use numeric characters, for example, 20/10/1983, instead of 20 October Block B. Approved Training Organisation (ATO) Enter the name of the approved course the applicant completed and indicate the test the ATO is endorsing the applicant to take. 1. Date. Enter the date an ATO official signs the application as eight digits (dd/mm/yyyy). Use numeric characters, for example, 20/10/1983, instead of 20 October ATO name. Enter the name of the ATO as sho n on the graduation certificate. 3. ATO certificate number. Enter the ATO certificate number as sho n on the graduation certificate. 4. Name, title and signature of ATO official. Print the name and ATO position title, and sign. Block C. CAA Authorisation 1. Check the box if the applicantmeets the requirements to take the applicable kno ledge test. Check the appropriate box to indicate if this is the applicant s initial kno ledge test, a re-take of a passing test or a re-test after failure of a kno ledge test. 2. Check the box if the applicant does not meet the requirements to take the applicable kno ledge test. 3. Enter remarks, as needed. 4.Print the name and title of the CAA official ho conducted the revie. Sign and date the application. Enter the date as eight digits (dd/mm/yyyy). Use numeric characters, for example, 20/10/1983, instead of 20 October II. Endorsement for the Skill Test Block A. Authorised Instructor 1. Date. Enter the date you sign the application as eight digits (dd/mm/yyyy). Use numeric characters, for example, 20/10/1983, instead of 20 October Instructor s name and signature. Authorised instructor should print and sign name. 3. Instructor s licence number. Enter the instructor s licence number. 4. Instructor s licence expiration date. Enter the expiration date of the instructor licence as eight digits (dd/mm/yyyy). Use numeric characters, for example, 20/10/1983, instead of 20 October Block B. Approved Training Organisation (ATO) Enter the name of the approved course the applicant completed and indicate the test the ATO is endorsing the applicant to take. 1. Date. Enter the date an ATO official signs the application as eight digits (dd/mm/yyyy). Use numeric characters, for example, 20/10/1983, instead of 20 October ATO name. Enter the name of the ATO as sho n on the graduation certificate. 3. ATO certificate number. Enter the ATO certificate number as sho n on the graduation certificate. 4. Name, title and signature of ATO official. Print the name and ATO position title, and sign. Agence Nationale de l Aviation Civile du Bénin formulaire de demande : licence de technicien de maintenance d aéronefs (TMA), qualification, conversion ou validation Block C. CAA Authorisation 1. Check the box if the applicantmeets the requirements to take the applicable skill test. Check the appropriate box to indicate if this is the applicant s initial skill test, a re-test after failure of a skill test, a rene al or re-issue. 2. Check the box if the applicant does not meet the requirements to take the applicable kno ledge test. 3. Enter remarks, as needed. 4. Print the name and title of the CAA official ho conducted the revie. Sign and date the application. Enter the date as eight digits (dd/mm/yyyy). Use numeric characters, for example, 20/10/1983, instead of 20 October III. Mechanic Skill Test esult Block 1. General Skill Test 1a Oral. Check the appropriate box to indicate if the applicant passed or failed the oral test. If the applicant passed the test, enter an expiration date as 24 calendar months from the date of the test. Enter eight digits (dd/mm/yyyy). Use numeric characters, for example, 20/10/1983, instead of 20 October If the applicant failed the test, enter the corresponding area of operation letter, task number, and element letter(s) from the Skill Test Standards (STS) booklet in the appropriate question number box. 1b Practical.Check the appropriate box to indicate if the applicant passed or failed the practical test. If the applicant passed the test, enter an expiration date as 24 calendar months from the date of the test. Enter eight digits (dd/mm/yyyy). Use numeric characters, for example, 20/10/1983, instead of 20 October If the applicant failed the test, enter the corresponding area of operation letter, task number, and element letter(s) from the Skill Test Standards (STS) booklet in the appropriate task number box. Enter the area of operation(s) failed in the emarks column. Block 2. Airframe ating Skill Test Airframe Structures 2a Oral. Check the appropriate box to indicate if the applicant passed or failed the oral test. If the applicant passed the test, enter an expiration date as 24 calendar months from the date of the test. Enter eight digits (dd/mm/yyyy). Use numeric characters, for example, 20/10/1983, instead of 20 October If the applicant failed the test, enter the corresponding area of operation letter, task number, and element letter(s) from the Skill Test Standards (STS) booklet in the appropriate question number box. 2b Practical.Check the appropriate box to indicate if the applicant passed or failed the practical test. If the applicant passed the test, enter an expiration date as 24 calendar months from the date of the test. Enter eight digits (dd/mm/yyyy). Use numeric characters, for example, 20/10/1983, instead of 20 October If the applicant failed the test, enter the corresponding area of operation letter, task number, and element letter(s) from the Skill Test Standards (STS) booklet in the appropriate task number box. Enter the area of operation(s) failed in the emarks column. Airframe Systems and Components 2c Oral. Check the appropriate box to indicate if the applicant passed or failed the oral test. If the applicant passed the test, enter an expiration date as 24 calendar months from the date of the test. Enter eight digits (dd/mm/yyyy). Use numeric characters, for example, 20/10/1983, instead of 20 October If the applicant failed the test, enter the corresponding area of operation letter, task number, and element letter(s) from the Skill Test Standards (STS) booklet in the appropriate question number box. 2d Practical.Check the appropriate box to indicate if the applicant passed or failed the practical test. If the applicant passed the test, enter an expiration date as 24 calendar months from the date of the test. Enter eight digits (dd/mm/yyyy). Use numeric characters, for example, 20/10/1983, instead of 20 October If the applicant failed the test, enter the corresponding area of operation letter, task number, and element letter(s) from the Skill Test Standards (STS) booklet in the appropriate task number box. Enter the area of operation(s) failed in the emarks column. 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14 Block 3. Po erplant ating Skill Test Po erplant Theory and Maintenance 3a Oral. Check the appropriate box to indicate if the applicant passed or failed the oral test. If the applicant passed the test, enter an expiration date as 24 calendar months from the date of the test. Enter eight digits (dd/mm/yyyy). Use numeric characters, for example, 20/10/1983, instead of 20 October If the applicant failed the test, enter the corresponding area of operation letter, task number, and element letter(s) from the Skill Test Standards (STS) booklet in the appropriate question number box. 3b Practical.Check the appropriate box to indicate if the applicant passed or failed the practical test. If the applicant passed the test, enter an expiration date as 24 calendar months from the date of the test. Enter eight digits (dd/mm/yyyy). Use numeric characters, for example, 20/10/1983, instead of 20 October If the applicant failed the test, enter the corresponding area of operation letter, task number, and element letter(s) from the Skill Test Standards (STS) booklet in the appropriate task number box. Enter the area of operation(s) failed in the emarks column. Po erplant Systems and Components 3c Oral. Check the appropriate box to indicate if the applicant passed or failed the oral test. If the applicant passed the test, enter an expiration date as 24 calendar months from the date of the test. Enter eight digits (dd/mm/yyyy). Use numeric characters, for example, 20/10/1983, instead of 20 October If the applicant failed the test, enter the corresponding area of operation letter, task number, and element letter(s) from the Skill Test Standards (STS) booklet in the appropriate question number box. 3d Practical.Check the appropriate box to indicate if the applicant passed or failed the practical test. If the applicant passed the test, enter an expiration date as 24 calendar months from the date of the test. Enter eight digits (dd/mm/yyyy). Use numeric characters, for example, 20/10/1983, instead of 20 October If the applicant failed the test, enter the corresponding area of operation letter, task number, and element letter(s) from the Skill Test Standards (STS) booklet in the appropriate task number box. Enter the area of operation(s) failed in the emarks column. Block 4. Avionics ating Skill Test 4a Oral. Check the appropriate box to indicate if the applicant passed or failed the oral test. If the applicant passed the test, enter an expiration date as 24 calendar months from the date of the test. Enter eight digits (dd/mm/yyyy). Use numeric characters, for example, 20/10/1983, instead of 20 October If the applicant failed the test, enter the corresponding area of operation letter, task number, and element letter(s) from the Skill Test Standards (STS) booklet in the appropriate question number box. 4b Practical.Check the appropriate box to indicate if the applicant passed or failed the practical test. If the applicant passed the test, enter an expiration date as 24 calendar months from the date of the test. Enter eight digits (dd/mm/yyyy). Use numeric characters, for example, 20/10/1983, instead of 20 October If the applicant failed the test, enter the corresponding area of operation letter, task number, and element letter(s) from the Skill Test Standards (STS) booklet in the appropriate task number box. Enter the area of operation(s) failed in the emarks column. IX. Skill Test eport (Examiner or CAA Inspector) Block 1. Examiner or inspector statement. Items a, b, and c must be addressed. a.the examiner/inspector must check the box to indicate that he/she personally revie ed the applicant s documents and the applicant meets the pertinent requirements of the MCA s. b.the examiner/inspector must check the box to indicate that he/she personally tested the applicant in accordance ith the pertinent procedures and requirements. Indicate if the applicant is approved or disapproved by checking the appropriate box. c.the examiner/inspector must check the box that he/she personally checked the applicant s language proficiency for both the language of Benin and the English language. Agence Nationale de l Aviation Civile du Bénin formulaire de demande : licence de technicien de maintenance d aéronefs (TMA), qualification, conversion ou validation Block 2. Location of test (facility, city, state or province, country). Enter the test facility name and location. Block 3. Licence, rating or certificate for hich tested. Enter the licence, rating or certificate for hich tested. Block 4. Attachments. Check to indicate that applicable documentation is attached. Block 5. Date. Enter the test date as eight digits (dd/mm/yyyy). Use numeric characters, for example, 20/10/1983, instead of 20 October Block 6. Examiner s or inspector s name and signature. Print and sign your name. Block 7. Examiner s designation number or inspector s licence number. Enter the examiner s designation number or the inspector s licence number. Block 8. Examiner s designation expiration date. Enter the examiner s designation expiration date as eight digits (dd/mm/yyyy). Use numeric characters, for example, 20/10/1983, instead of 20 October X. CAA eport Block A. CAA Action. Check the appropriate box. Block B. Attachments. Check to indicate that applicable documentation is attached. Block C. Applicant s Identification. Enter the type of government-issued identification, the identification number, and the expiration date. Block D. CAA Authorisation. Check the appropriate box to indicate if the applicant meets the licensing requirements or if the application is incomplete and ill be returned to the applicant. Print the name and title of the CAA official ho conducted the revie and sign the application. Enter the date of the revie as eight digits (dd/mm/yyyy). Use numeric characters, for example, 20/10/1983, instead of 20 October XI. CAA Issuance Block A. Licence, ating or alidation Certificate issued. Check the appropriate box and indicate the grade of licence, rating(s) or validation certificate received. Enter the expiration date as eight digits (dd/mm/yyyy). Use numeric characters, for example, 20/10/1983, instead of 20 October Block B. CAA Authorisation. Print the name and title of the CAA official ho completed the issuance and sign the application. Enter the date of the issuance as eight digits (dd/mm/yyyy). Use numeric characters, for example, 20/10/1983, instead of 20 October Page 14 sur 14 MXL-01 / ANAC BENIN