CPR-nr./Date of Birth: Certifikat nr/Licence no: Udstedende Stat/State of Licence Issue:

Fornavne/First name(s): Efternavn/Last name:

Total flight time: Total time single-engine piston or TMG:

Time single-engine piston last 6 months:

Total instrument flight time: Cross-country hours

Flight time Multi-Engine aeroplane (If applying for instructor rating multi-engine)

Total PIC on Class/Type (State Class or type): Flight time on mentioned Class/Type last 12 months:

Date of signature Signature:

FLIGHT INSTRUCTOR FIASSESSMENT OF COMPETENCE

FI(A) Restricted FI(A) IRI(A) CRI SPA ME CRI SPA SE

FI(A) incl. IR FI(A) incl. CR SPA ME FI(A) incl. FI

Application and Report form

A. To be filled out by the applicant:

B. Pre-entry Flight Test (if required):Name of ATO:

I hereby recommend the above mentioned applicant to begin Flight Instructor(A) Course

Date of Pre-entry Flight Test Name of FI(A) conducting the test: Signature of FI(A):

C. To be filled out by the Examiner of Section 1 (if required):

Date of assessment: Name of Examiner: Examiner authorisation no.:

I hereby verify that the applicant has passed the required training and that the applicant fulfills the requirement for the issue of the applicable instructor rating section 1. I also declare that I have reviewed and applied the relevant national procedures and requirements of the applicant’s competent authority contained in the latest version of the Examiner Differences Document.

Date of signature of Examiner Signature of Examiner

Result of Section 1:

Passed Failed

Remaining sections shall be completed before: (Date)

D. To be completed by the Examiner of Section 2 to 7:

Date of assessment: Name of Examiner or stamp: Examiner authorisation no.:

I hereby verify that the applicant has passed the required training and that the applicant fulfills the requirement for the issue of the applicable instructor rating section 2 – 7. I also declare that I have reviewed and applied the relevant national procedures and requirements of the appli- cant’s competent authority contained in the latest version of the Examiner Differences Document.

Date of signature of Examiner Signature of Examiner

Result of the assessment

Section 2:

Passed Failed

Section 3:

Passed Failed

Section 4:

Passed Failed

Section 5:

Passed Failed

Section 6:

Passed Failed

Section 7:

Passed Failed

Final result Section 2 to 7: Passed Failed

Signature

1 of 5

Total instructional hours

FI(B)

FI(S)

FI(S) Restricted

Instructor FI - March 2021

Certification by Head of Training or Chief Ground Instructor: Name of ATO: (Use stamp):

I hereby certify that the applicant has passed the required theoretical training and that the appli- cant fulfils the requirement for the issue of:

FI(A) FI(S) FI(B) IRI(A) CRI SPA ME CRI SPA SE and I hereby apply for the assessment of competence Section

1. Date for start of training Date for end of training

Date of signature CGI Signature of CGI

Section 1

Part 1:Teaching and Learning

a Visual Presentation

Comments:

b Technical Accuracy

c Clarity of Explanation

d Clarity of Speech

e Instructional Technique

f Use of Models and Aids

g Student Participation

Part 2: Theoretical Knowledge Oral

a Air Law Comments:

B Aircraft General Knowledge

C Flight Performance and Planning

D Human Performance and Limitations

E Meteorology

F Navigation

G Operational Procedures

H Principles of Flight

I Training Administration

Result Section 1: Passed/Failed. Signature Examiner:

Signature of Applicant:

2 of 5Instructor FI - March 2021

Certification by Head of Training or Chief Flight Instructor: Name of ATO: (Use stamp):

Theoretical knowledge instruction hours: Teaching and learning hours:

Date for start of flight training Date for end of flight training: Flight time during training: Mutual flying:

Date of signature of CFI or HT Signature of CFI or HT

SECTION 2 Pre-Flight Briefing Passed Failed

a Visual Presentation Comments:

b Technical Accuracy

c Clarity of Explanation

d Clarity of Speech

e Instructional Technique

f Use of Models and Aids

g Student Participation

Result Section 2 Passed Failed

SECTION 3 Flight Passed Failed

a Arrangements of Demo Comments:

b Synchronisation of Speech with Demo

c Correction of Faults

d Aircraft handling

e Instructional Technique

f General Airmanship/Safety

g Positioning Use of Airspace

Result Section 3 Passed Failed

SECTION 4 Other Exercises Passed Failed

a Comments:

b

c

d

e

f

g

Result Section 4 Passed Failed Not Applicable

3 of 5Instructor FI - March 2021

SECTION 5 Multi-Engine Exercises These exercises shall be demonstrated for the single pilot multi-engine class rating instructor rating (CRI SPA ME)

Passed Failed

a Actions following an Engine failure shortly after take-off

Comments:

b A single-engine approach and go around

c A single-engine approach and landing

d

e

f

g

Result Section 5 Passed Failed Not Applicable

SECTION 6 Instrument Exercises Passed Failed

a Comments:

b

c

d

e

f

g

Result Section 6 Passed Failed Not Applicable

SECTION 7 Postflight De-Briefing Passed Failed

a Visual Presentation Comments:

b Technical Accuracy

c Clarity of Explanation

d Clarity of Speech

e Instructional Technique

f Use of Models and Aids

g Student Participation

Result Section 7 Passed Failed

Details of the flight Aircraft Type: Aircraft registration: On block On ground

Departure aerodrome Off block Airborne

Destination aerodrome Total block time Total airborne time No. of landings:

Remarks/Overall assessment/Reasons for failure (if applicable):

Name of instructor present at the assessment:

Signature of Examiner Signature of Applicant:

4 of 5Instructor FI - March2021

In accordance with ARA.GEN.315(a), (b) – (c)

Undertegnede bekræfter hermed, at jeg ved ansøgningstidspunktet

1. ikke var i besiddelse af et personligt certifikat, rating, tilladelse ellerattestation med samme anvendelsesområde og i samme kategori udstedt i en anden medlems- stat;

2. ikke har ansøgt om et personligt certifikat, rating, tilladelse ellerattestation med samme anvendelsesområde og i samme kategori i en anden medlemsstat; og

3. aldrig har haft et personligt certifikat, rating, tilladelse eller attestmed samme anvendelsesområde og i samme kategori udstedt i en anden medlemsstat, som ertilbagekaldt eller suspenderet i anden medlemsstat.

Note:

Ukorrekte oplysninger vedrørende ovenstående, kan være diskvalificerende for udstedelse af certifikat, rating, tilladelse m.v.

Undersigned hereby confirm that I at the time of application

1. was not holding any personnel licence, certificate, rating, authorisation orattestation with the same scope and in the same category issued in anotherMember State;

2. has not applied for any personnel licence, certificate, rating, authorisation orattestation with the same scope and in the same category in another MemberState; and

3. has never held any personnel licence, certificate, rating, authorisation or attestation

with the same scope and in the same category issued in another Member Statewhich was revoked or suspended in any other Member State.

4. Note:

Incorrect information regarding the above can be disqualifying for obtaining a certificate, rating, authori- zation, etc.

Dato:/Date:

Underskrift:/Signature:

5 of 5

Side 1 (3)

Carsten Niebuhrs Gade 43

1577 København V Telefon 7221 8800

Fax 7262 6790

info@trafikstyrelsen.dk

www.trafikstyrelsen.dk

Notat

Persondatabeskyttelse

I henhold til EU’s databeskyttelsesforordning (GDPR) vil vi i det føl-

gende oplyse dig om, hvordan styrelsen håndterer de personoplysnin-

ger, som vi modtager og behandler om dig.

Vi er dataansvarlig – hvordan kontakter du os?

Trafikstyrelsen er dataansvarlig for behandlingen af de

personoplysninger, som vi modtager om dig. Hvis du har spørgs'mål

til styrelsens behandling af dine personoplysninger, er du altid

velkommen til at kontakte os eller Transportministeriets uafhængige

databeskyttelsesrådgiver via kontaktoplysninger-ne nedenfor:

Styrelsens kontaktoplysninger

Carstens Niebuhrs Gade 43 1577 København VTelefon: 7221 8800

E-mail: info@trafikstyrelsen.dk

CVR-nr.: 27186386

Databeskyttelsesrådgivers kontaktoplysninger

E-mail: dpo@trafikstyrelsen.dk

Telefon: 41780531

Formålene med behandlingen af dine personoplysninger

Styrelsen behandler dine personoplysninger til følgende formål:

Udstedelse af instruktørcertifikat.

Notat

Retsgrundlaget for behandlingen af dine personoplysninger

Retsgrundlaget for vores behandling af dine personoplysninger følger

af:

Kommissionens forordning (EU) nr. 1178/2011 af 3. november 2011

om fastsættelse af tekniske krav og administrative procedurer for fly-

vebesætninger i civil luftfart i henhold til Europa-Parlamentets og Rå-

dets forordning (EF) nr. 216/2008 EØS-relevant tekst

Kategorier af personoplysninger

Styrelsen behandler følgende kategorier af personoplysninger om dig:

CPR-nummer

Navn, adresse, e-mail, telefon, certifikatnummer, eksamensresultat -

NB. navn på instruktør, examiner og examiner autorisationsnummer,

evt. samt navn på Head of Training

Modtagere eller kategorier af modtagere

Styrelsen videregiver eller overlader dine personoplysninger til følgen-

de modtagere:

I forbindelse med tilsyn med Trafikstyrelsens myndighedsudøvelse, kan EASA (European Aviation Safety Agency) kræve at få doku-menter med dine persondata udleveret som led i tilsynet. EASA er hjemmehørende i Tyskland.

Overførsel til modtagere i tredjelande, herunder internationale

organisationer

I forbindelse med tilsyn med Trafikstyrelsens myndighedsudøvelse, kan ICAO

(International Civil Aviation Organization) kræve at få doku-menter med dine

persondata udleveret som led i tilsynet. ICAO er en FN-organisation

hjemmehørende i Canada.

Hvor dine personoplysninger stammer fra

Fra ansøger.

Opbevaring af dine personoplysninger

De oplysninger, styrelsen skal journalisere, afleveres løbende til Rigs-

arkivet efter arkivlovens regler og Statens Arkivers bestemmelser

herom. Oplysninger vi modtager, der ikke er omfattet af styrelsens

pligt til at journalisere, vil blive slettet, når vi ikke længere har behov

for dem.

Side 2 (3)

Notat

Dine rettigheder

Du har efter databeskyttelsesforordningen en række rettigheder i for-

hold til vores behandling af oplysninger om dig. Hvis du vil gøre brug

af dine rettigheder skal du kontakte os.

Ret til at se oplysninger

Du har ret til at få indsigt i de oplysninger om dig, som vi behandler

(indsigtsret), eller til at søge om aktindsigt.

Ret til berigtigelse

Du har ret til at få urigtige oplysninger om dig selv rettet.

Ret til sletning

I særlige tilfælde har du ret til at få slettet oplysninger om dig, inden

tidspunktet for vores almindelige generelle sletning indtræffer. Det

gælder alene oplysninger, som ikke er journaliseringspligtige.

Du kan læse mere om dine rettigheder i Datatilsynets vejledning om

de registreredes rettigheder, som du finder på www.datatilsynet.dk.

Klage til Datatilsynet

Du har ret til at indgive en klage til Datatilsynet, hvis du er utilfreds

med den måde, vi behandler dine personoplysninger på. Du finder Da-

tatilsynets kontaktoplysninger på www.datatilsynet.dk.

Side 3 (3)