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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.
Form SRG 1411 (June 2010) Page 1 of 4
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 a 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: ..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
County: .................................................. Country: ............................................. Postcode: ..................................
Postal Address: ..............................................................................................................................................................................
(normally unit address) ..............................................................................................................................................................................
..............................................................................................................................................................................
County: .................................................. Country: ............................................. Postcode: ..................................
Telephone Numbers: Home: ...................................................................................................................................................................
(incl. area code) Office: ...................................................................................................................................................................
SECTION 3)UNIT ENDORSEMENT APPLIED FOR:
Location of examination: ................................................................. Proposed date (dd/mm/yyyy): ........................................................
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
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
Form SRG 1411 (June 2010) Page 2 of 4
ACP Area Control Procedure OCN Oceanic
*Sector/Position(s) (if appropriate) ACS Area Control Surveillance RAD Radar
..................................................... TCL Terminal Control
..................................................... OFF Offshore
..................................................... SPT Special Tasks
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: ..................................................
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 PLD at the address on
page 4.
Unit Endorsement Exam postponed – alternative date to be arranged with SRG Regional Office and new form SRG 1411 to be
submitted.
Unit Endorsement Exam cancelled – no alternative date will be arranged.
Signed .............................................................................................
SECTION 3)UNIT ENDORSEMENT APPLIED FOR:
Form SRG 1411 (June 2010) Page 3 of 4
SECTION 5)ENGLISH LANGUAGE 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/EGXX Tower) Date expired/withdrawn (dd/mm/yyyy)
..................................................................................................................................................... ............................................................
..................................................................................................................................................... ............................................................
SECTION 7)DECLARATION
Article 231 of the Air Navigation Order 2009 (as amended) provides that a person shall not make any false representation for procuring
himself, or any other person, the grant, renewal or re-certification of any certificate or licence.
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
I, the undersigned, hereby certify (delete as appropriate):
• The details of the air traffic control training are correct and in accordance with CAP 584 and CAP 744 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: ..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
County: .................................................. Country: ............................................. Postcode: ..................................
SECTION 8)CAA CHARGES (Refer to the Scheme of Charges at www.caa.co.uk/schemeofcharges)
I enclose the remittance of £......... . ........ p
Form SRG 1411 (June 2010) Page 4 of 4
SUBMISSION INSTRUCTIONS
Please check:
• Section 2 (Personal Details) has been fully completed, including the applicant’s ATC licence number (if held);
• All other Sections relevant to the application have been completed (refer to Section 1);
• The declaration has been signed by the applicant and a signatory for the relevant authority (refer to Section 7); and
• The correct remittance is included with the application (refer to Section 8).
When completed, return this form to: ATS Licensing Section,
Licensing and Training Standards,
Safety Regulation Group,
Civil Aviation Authority,
Ground Floor,
Aviation House,
Gatwick Airport South
West Sussex RH6 0YR
Telephone Enquiries: +44 (0) 1293 573270
e-mail: ats.licensing@caa.co.uk

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