Part-66 Aircraft Maintenance Licence

Application for Written Examination CAA International Overseas Exam Centres

FALSE REPRESENTATION STATEMENT
It is an offence under Article 231 of the Air Navigation Order 2009 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. This offence is punishable on summary conviction by a fine up to 5,000, and on conviction on indictment with an unlimited fine or up to two years imprisonment or both. Please complete this form online then print, sign and submit as instructed. Alternatively, print and complete in BLOCK CAPITALS using black or dark blue ink.

1. Personal Details
CAA Personal Reference Number (if known) Examination Reference Number (if known) Surname Title Town of Birth Permanent Address City Telephone No. Email Address Address for correspondence if different from above Address City Postcode / Zip Code Country Postcode / Zip Code Country Alternative Tel. No.
(DD/MM/YYYY)

9/93 Forename(s)

Date of Birth

Nationality Country of Birth

2. CAA International Exam Centre

Exam Centre AM PM Exam Date 2nd Choice

Exam Date 1st Choice

Please see our website www.caainternational.com for exam dates and venues.

3. Category / Sub Category Of Examination (tick as appropriate)

Category Aeroplane Turbine Aeroplane Piston Helicopter Turbine Helicopter Piston Avionic Aeroplane Piston 2000 kg and below A A1 A2 A3 A4 N/A N/A B B1-1 B1-2 B1-3 B1-4 B2 B3

4. For CAAi Use Only

Date Enclosures Cheque/PO/Cash/MasterCard/Visa Receipt No.
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Form CAAi 1002 (EASA Form 19E CAAi Version)

5. Additional Information
I am applying to take examinations to remove limitations from my Part-66 Licence. I hold a Part-66 Licence in a different category to the examinations for which I am applying.

6. Examination Papers (Please put check box(es) against the module(s) you wish to take at this examination)
Module CAAi Use Only
Paper No. Time

Module

CAAi Use Only

Paper No. Time

1. Mathematics 2. Physics 3. Electrical Fundamentals 4. Electronic Fundamentals 5. Digital Techniques / Electronic Instrument Systems 6. Materials & Hardware 7. Maintenance Practices 8. Basic Aerodynamics 9. Human Factors

10. Aviation Legislation 11. Aeroplanes Aerodynamics, Structures and Systems 12. Helicopter Aerodynamics, Structures and Systems 13. Aircraft Aerodynamics, Structures and Systems 14. Propulsion 15. Gas Turbine Engine 16. Piston Engine 17. Propellor

Essay

Module 7 Maintenance Practices

Module 9 Human Factors

Module 10 Aviation Legislation

All

7. Declaration
I declare that the information provided on this form is correct. I declare that I have not taken the above module exams within the last 90 days. I confirm that I comply with the regulation Part-66 Appendix II 1.B (the maximum number of consecutive attempts for each module is 3. Further sets of 3 attempts are allowed with a 1 year period between sets. Any candidates first sitting of a module as of 1st August 2012 will be considered the first attempt of a new set of 3).

Signature

Date

8. Submission Instructions
Send your completed application form and payment to: CAA International, Examination Section, Aviation House, Gatwick Airport South, West Sussex, RH6 0YR, United Kingdom or by email to: exams@caainternational.com or by fax to: +44 (0) 1293 573992 Together with: a copy of your passport which has been certified as a true copy by a Quality Manager or similar, if this is your FIRST application for CAA Part-66 examinations.

Form CAAi 1002 (EASA Form 19E CAAi Version)

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9. Payment Details (Refer to our website for exam fees www.caainternational.com)

a) Payment type (please tick appropriate box) Visa MasterCard Debit Card Cheque/Bankers Draft Electronic Transfer

We do not accept American Express, Diners Club or JCB cards. Please do not send cash by post. b) Bank Details (for payment by Cheque/Bankers Draft) Cheques or Postal Orders should be made payable to CAA International Ltd. Please note that any refund applicable will be paid directly to the bank account stated below by BACS transfer. Name in which Bank Account held Account Number If overseas: IBAN Number c) CAA International Bank Account Details (if paying by Electronic Transfer) National Westminster Bank plc. Bloomsbury Parrs Branch PO Box 158 214 High Holborn London WC1V 7BX Please supply the following information: Amount BACS/CHAPS Reference Account Name: CAA International Ltd Account Number: 26625105 Sort Code: 60-30-06 Swift Code: NWBK GB 2L IBAN: GB97 NWBK 6030 0626 6251 05 Swift Code Sort Code

*When making an electronic transfer please instruct your bankers to quote the CAAi Application Form number followed by the application date and exam venue in the description field (i.e. Form CAAi 1002dd/mm/yyyy Delhi). Payer Date of Transfer

d) Card Details (for payment by Credit/Debit Card) Card Number

(16 digits)

Expiry Date
(MM/YY)

Security Code

(last 3 digits on signature strip on reverse of card)

Debit Cards Only: Start Date

(MM/YY)

Issue No.
(if applicable)

Amount

Name (as written on card) BLOCK CAPITALS Full postal address of card holder Postcode / Zip Code Card Holders Signature Please tick the box if paying with Company Card Company Name

This information is provided at the applicants risk and will be used by CAAi for this payment only and will not be used for any other purpose.
Form CAAi 1002 (EASA Form 19E CAAi Version) Page 3 of 3