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APPLICATION FORM All Information You Furnish Is Treated in Confidence and Will Not Be Used Without Your Permission

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APPLICATION FORM All Information You Furnish Is Treated in Confidence and Will Not Be Used Without Your Permission APPLICATION FORM All information you furnish is treated in confidence and will not be used without your permission. Ensure that your employment record is continuous. If the space allowed for any question is insufficient please use a separate sheet. Please print (No hand writing) NOTE: Follow the instructions and format EXACTLY as describe or Air Japan staff will disqualify your application. SURNAME : Doe FORENAME(S) : John Paul If you have name in Chinese/Japanese character, please print. DATE OF BIRTH (DD/MM/YY) : 01/02/80 HEIGHT (Centimetres) : 176 WEIGHT (Kilograms) : 82 POSITION APPLYING FOR ; CAPTAIN, F/O PASSPORT DETAILS The Issue and Expiry date should be the same with attached copy. PASSPORT NO 1 NA569825 PASSPORT NO 2 COUNTRY USA COUNTRY (DD/MM/YY) (DD/MM/YY) DATE OF ISSUE 09/02/17 DATE OF ISSUE (DD/MM/YY) (DD/MM/YY) DATE OF EXPIRY 09/02/16 DATE OF EXPIRY CONTACT DETAILS PERMANENT ADDRESS TEMPORARY ADDRESS 12 Main Street CITY Springfield CITY STATE N/A STATE ZIP CODE 91234 ZIP CODE COUNTRY USA COUNTRY TELEPHONE +1 415 522 8444 TELEPHONE FAX NO +1 415 522 8444 FAX NO MOBILE +1 23456789 MOBILE E-MAIL 1 [email protected] E-MAIL 1 E-MAIL 2 N/A E-MAIL 2 LICENCE ATPL LICENSE 1 (Current Licence) ATPL LICENSE 2 NUMBER 123456 NUMBER A320 COMMAND COMMAND TYPE RATINGS TYPE RATINGS COUNTRY OF ISSUE USA COUNTRY OF ISSUE (DD/MM/YY) (DD/MM/YY) DATE OF ISSUE 26/08/13 DATE OF ISSUE (DD/MM/YY) (DD/MM/YY) DATE OF EXPIRY Perpetual DATE OF EXPIRY (DD/MM/YY) (DD/MM/YY) INSTRUMENT RATING 26/08/13 INSTRUMENT RATING (DD/MM/YY) (DD/MM/YY) DATE OF EXPIRY Perpetual DATE OF EXPIRY (DD/MM/YY) (DD/MM/YY) Radio ISSUE 20/04/94 Radio ISSUE ICAO English Level 5 ICAO English Level (DD/MM/YY) (DD/MM/YY) DATE OF LAST MEDICAL 25/05/13 DATE OF LAST MEDICAL (DD/MM/YY) (DD/MM/YY) DATE OF EXPIRY OF MED DATE OF EXPIRY OF MED 22/06/14 Be sure that you have the right Version (AUG 2017) OLD Versions will not be accepted. AUG2017 EMPLOYMENT HISTORY (If the space allowed is insufficient use a separate sheet) FROM(MM/YY) TO(MM/YY) COMPANY Currency / Salary(MONTH) REASON FOR LEAVING: 10/13 Present Pacific USA Airlines 7000USD Job Advancement SUPERVISOR: ADDRESS, CITY, STATE, ZIPCODE: PHONE: Captain A. America 12 Boeing Drive, Los Angeles Airport, California, USA +415 333 4444 AIRCRAFT(S): DUTY / POSITION FLT TIME: FROM(MM/YY): TO(MM/YY): A320 First Officer 892:42 10/13 Present FOR OFFICE USE ONLY: NAME: DISCREPANCY(IES): NOTES: DATE: TIME: YES / NO FROM(MM/YY) TO(MM/YY) COMPANY Currency / Salary(MONTH) REASON FOR LEAVING: 01/11 09/13 West Pacific Airlines 6000USD Airline Bankrupt SUPERVISOR: ADDRESS, CITY, STATE, ZIPCODE: PHONE: Captain K. F See 20 Airbus Street, Seattle Airport, Washington, USA +360 123 5555 AIRCRAFT(S): DUTY / POSITION FLT TIME: FROM(MM/YY): TO(MM/YY): A320 First Officer 1575:24 01/11 09/13 A321 First Officer 171:54 01/11 09/13 FOR OFFICE USE ONLY: NAME: DISCREPANCY(IES): NOTES: DATE: TIME: YES / NO FROM(MM/YY) TO(MM/YY) COMPANY Currency / Salary(MONTH) REASON FOR LEAVING: 11/08 09/10 Acme Air 2000USD Hired by West Pacific SUPERVISOR: ADDRESS, CITY, STATE, ZIPCODE: PHONE: Captain Iran Jaya Jalan Merdeka 300, Pangandaran, West Java, 444444, Indonesia +62 2234 56780 AIRCRAFT(S): DUTY / POSITION FLT TIME: FROM(MM/YY): TO(MM/YY): C208 Captain 597:36 12/09 09/10 C208 First Officer 630:18 11/08 11/09 FOR OFFICE USE ONLY: NAME: DISCREPANCY(IES): NOTES: DATE: TIME: YES / NO FROM(MM/YY) TO(MM/YY) COMPANY Currency / Salary(MONTH) REASON FOR LEAVING: SUPERVISOR: ADDRESS, CITY, STATE, ZIPCODE: PHONE: AIRCRAFT(S): DUTY / POSITION FLT TIME: FROM(MM/YY): TO(MM/YY): FOR OFFICE USE ONLY: NAME: DISCREPANCY(IES): NOTES: DATE: TIME: YES / NO FROM(MM/YY) TO(MM/YY) COMPANY Currency / Salary(MONTH) REASON FOR LEAVING: SUPERVISOR: ADDRESS, CITY, STATE, ZIPCODE: PHONE: AIRCRAFT(S): DUTY / POSITION FLT TIME: FROM(MM/YY): TO(MM/YY): FOR OFFICE USE ONLY: NAME: DISCREPANCY(IES): NOTES: DATE: TIME: YES / NO AUG2016 GENERAL AVIATION and NON-Aviation Employment History FROM(MM/YY) TO(MM/YY) COMPANY Currency / Salary(MONTH) REASON FOR LEAVING: 03/08 10/08 Chevron Aviation 500USD This was a part time job to support me during flight training. I left when Acme Air offered me a position. SUPERVISOR: ADDRESS, CITY, STATE, ZIPCODE: PHONE: Mr H Burger 1234 Main Street, San Francisco, California, USA +1 415 345 6789 AIRCRAFT(S): DUTY / POSITION FLT TIME: FROM(MM/YY): TO(MM/YY): N/A Fueler N/A 03/08 10/08 FOR OFFICE USE ONLY: NAME: DISCREPANCY(IES): NOTES: DATE: TIME: YES / NO FROM(MM/YY) TO(MM/YY) COMPANY Currency / Salary(MONTH) REASON FOR LEAVING: 12/05 10/08 Taco Bell 500USD This was a part time job to support me while I was at University SUPERVISOR: ADDRESS, CITY, STATE, ZIPCODE: PHONE: Mr. B Bio 1234 Kirk Street, San Francisco, California, USA +1 415 345 9999 AIRCRAFT(S): DUTY / POSITION FLT TIME: FROM(MM/YY): TO(MM/YY): N/A Cook N/A 12/05 10/08 FOR OFFICE USE ONLY: NAME: DISCREPANCY(IES): NOTES: DATE: TIME: YES / NO FROM(MM/YY) TO(MM/YY) COMPANY Currency / Salary(MONTH) REASON FOR LEAVING: SUPERVISOR: ADDRESS, CITY, STATE, ZIPCODE: PHONE: AIRCRAFT(S): DUTY / POSITION FLT TIME: FROM(MM/YY): TO(MM/YY): FOR OFFICE USE ONLY: NAME: DISCREPANCY(IES): NOTES: DATE: TIME: YES / NO FROM(MM/YY) TO(MM/YY) COMPANY Currency / Salary(MONTH) REASON FOR LEAVING: SUPERVISOR: ADDRESS, CITY, STATE, ZIPCODE: PHONE: AIRCRAFT(S): DUTY / POSITION FLT TIME: FROM(MM/YY): TO(MM/YY): FOR OFFICE USE ONLY: NAME: DISCREPANCY(IES): NOTES: DATE: TIME: YES / NO TRAINING Back Ground Information (Advice ALL Information required) *Advice when and where you earned below:- (MM/YY) (COUNTRY) (PLACE / CITY) (Memo / Notes) PPL 03/12 USA Central Aviation Training Centre, Florida (MM/YY) (COUNTRY) (PLACE / CITY) (Memo / Notes) CPL 09/14 USA Central Aviation Training Centre, Florida (MM/YY) (COUNTRY) (PLACE / CITY) (Memo / Notes) MEL 09/14 USA Central Aviation Training Centre, Florida (MM/YY) (COUNTRY) (PLACE / CITY) (Memo / Notes) IR 06/09 USA Central Aviation Training Centre, Florida (MM/YY) (COUNTRY) (PLACE / CITY) (Memo / Notes) ATPL 06/09 USA Central Aviation Training Centre, Florida AUG2016 PERIODS OF UNEMPLOYMENT Please account for any periods of unemployment of at least 30 days FROM(MM/YY) TO(MM/YY) REASON 03/13 05/13 Between Aviation Contracts INSTRUCTOR QUALIFICATIONS TRAINING QUALIFICATIONS AIRCRAFT AIRLINE (Line/Base/Ground/Sim etc) None None None FLYING EXPERIENCE FMS Equipped TOTAL TIME DATE OF LAST Glass INSTRUCTOR FLIGHT AIRCRAFT Cockpit TIME Command Co-Pilot (DD/MM/YY) Yes No Time (P1) Time(P2) DUAL *including SOLO *Including PUS A321 171:54 12:06 05/07/13 A320 2468:06 20/10/14 C208 597:36 611:48 177:42 22/09/10 BE76 24/09/10 C172 88:48 28/03/12 1. When entering aircraft type please specify aircraft series (e.g. B737-200/B737Efis, B747/B747-400) 2. Command (P1) time does not include Cruise Captain time or P1u/s time 3. Do not include Simulator time in flight times TOTAL TIME: 4128:00 TOTAL JET TIME*: 1027:30 JET P1: 00:00 Dual Time can be less TTL P1 (with Solo): DUAL TIME: JET P2: 686:24 189:48 than in your logbook. 2640:00 TTL P2 (with PUS): 3251:48 / (*PUS: 487:32 ) TOTAL B757/B767 TIME: 00:00 INSTRUMENT TIME: 102:30 EFIS: 2640:00 NIGHT FLIGHT TIME : 1027:24 CROSS COUNTRY TIME: 3968:36 CROSS COUNTRY PIC TIME: 641:30 *CROSS COUNTRY PUS TIME: 128:24 Commercial Jet time only-Do not include Helicopter time Total Time = TTL P1 + TTL P2 + Dual Time (TTL P1 and TTL P2 must match your logbook. Dual Time can be less than your logbook since the JCAB does not concurrently log PIC and Dual after receiving your PPL. Dual Time is the only exception, all *PUS = P1US, ICUS time other flight times must match your logbook copies submitted. *Cross Country PUS Time must be put when Cross Country PIC time is less than 100H CURRENCY RECORD TOTAL FLYING HOURS IN LAST 6 AIRCRAFT TYPE: A321 P1: 0:00 P2: 142:06 MONTHS DATE OF LAST PROFICIENCY CHECK ; 01/17, A/C TYPE ; A321, RENEWAL ; 01/18. DATE OF LAST INSTRUMENT RATING ; 12/16, A/C TYPE ; A321, RENEWAL ; 12/17. AUG2016 ACCIDENTS/INCIDENTS/ATC VIOLATIONS Give details of any A/C accidents, incidents or ATC violations in which you have been involved: None BACK GROUND INFORMATION Have you ever been convicted of a criminal offence in a court of law? If yes give details. Yes / No (If Yes, give details:) Have you ever been convicted of a violation of any Federal or State Statute for DUI/DWI? Yes / No (If Yes, give details:) CURRENT EMPLOYMENT STATUS If you are currently employed, how are you planning to work for AJX ? 1. Resign from current position 2. Apply for LOA 3. Currently furloughed 4. Currently unemployed If your answer is 2 or 3, what is the maximum period of time you can apply for ? AVAILABILITY FOR EMPLOYMENT / NOTICE TERM When could you start training if offered position? How long is your notice of resignation to current employer? Please answer available date (DD/MM/YYYY) or notice term. 2 Months COMMUTING DETAILS If offered position, from which country and city are you planning to commute to Japan? Los Angeles, USA If the above commuting city is outside Asia or Oceania, are you willing to relocate if necessary? If so, where can you relocate? Brisbane, Australia EXPERIENCE OF OTHER AIRLINES APPLICATION Have you ever applied for ANA Group Companies (Air Japan/ANA & JP Express/ANK/ANA WINGS) previously? YES NO If yes, which company? Air Japan ANA & JP Express ANK ANA WINGS/A-net Yes, I underwent screening process in / ( mm / yy ) , which was successful / unsuccessful Have you ever applied for Japanese airlines previously? (i.e.
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