航空人員證照核發紀錄/裁處紀錄申請表

APPLICATION FORM
Airman Certification Records / Violation Sanction Records

A.申請項目 Application Items
1. 航空安全違規裁處紀錄及檢定證核發紀錄證明
Violation Sanction Records and Airman Certification Records 		份 Copy
2. 檢定證核發紀錄證明 Airman Certification Records Only 份 Copy
3. 其他 Others 份 Copy

B.申請人基本資料 Basic Information of Applicant
姓名(正楷與檢定證一致)
Name(Round hand/ coincide with License)
檢定證號碼 CAA License No
最後服務國籍公司 Last Service Airlines
聯絡電話 Phone Number(Mobile)
電子郵箱 E-mail Address
性別 Sex

C.檢附下列附件 Attachments
1. 身分證件影本 One Copy of ID or Passport(or ARC)
2. 檢定證影本 One Copy of License CAA, Taiwan
3. 申請其他事項之相關文件 Others If Required

D.注意事項 Notices
1. 本人無法領取時，受委託人於代領時，應出具委託書供查驗。
you are unable to pick up your Airman Certification Records/ Violation Sanction Records in person, you should fill out a power of attorney. The authorized person will show the power of attorney for verification when he /she acts on your behalf in the process of picking up record.
2. 通知領取日起1個月內前來領取，逾期且未繳費之申請案件作廢，請重新申辦。
Collect within 1 month when notified. The application will be declared void after the deadline.
3. 申請費用：每份新台幣350元　Processing Fee : NT$350/copy
4. 檢定證逾期1年以上者，僅核發檢定證核發紀錄證明。
Holder whose Certificate has been Overdue over 1 year can only request to apply for Airman Certificate Records.
5. FAX：02-2349-6101 Email：ujmik0262@mail.caa.gov.tw TEL：02-2349-6375

備註 Memo

E.申請日期 Application Date
2024/12/07

驗證碼 Verification code