<p> RECRUITMENT OF STUDENT AIR TRAFFIC CONTROLLERS FOR ADMISSION TO THE INITIAL SELECTION PROCEDURE</p><p>Confidential</p><p>Please complete all relevant fields. Answer each question clearly and completely in English. Any incomplete / missing answers will result in the application being returned to you. All details given will be treated in confidence. </p><p>1. SURNAME MAIDEN NAME (IF APPLICABLE) FORENAME</p><p>2. ADDRESS EMAIL</p><p>Tel. Work </p><p>Tel. Home </p><p>Mobile Tel. </p><p>3. PLACE OF BIRTH DATE OF BIRTH (DD/MM/YY) PRESENT NATIONALITY (IF DUAL, INDICATE BOTH)</p><p>4. MILITARY SERVICE COMPLETED NOT COMPLETED NOT REQUIRED</p><p>5. SEX M F</p><p>6. MARITAL STATUS SINGLE MARRIED OTHER (SPECIFY): (PUT A CROSS IN THE APPROPRIATE SQUARE)</p><p>European Organisation for the Safety of Air Navigation – Organisation européenne pour la sécurité de la navigation aérienne Maastricht UAC, Horsterweg 11, NL-6199 AC Maastricht Airport Tel. +31 433662017 or/ou 3661340 Fax. +31 433661463 Email/Mél : [email protected] http//:www.eurocontrol.int C o n f i d e n t i a l</p><p>GOOD POOR 7. GENERAL STATE OF HEALTH (IF DISABLED, STATE NATURE AND DEGREE OF DISABILITY) IF POOR, PLEASE IMPORTANT: GOOD HEARING AND VISUAL PERFORMANCE ARE ESSENTIAL.. EXPLAIN BELOW</p><p>PLEASE INDICATE FULL DETAILS OF YOUR VISION BELOW. IF THE INFORMATION BELOW ISN’T FULLY COMPLETED, YOUR APPLICATION WILL NOT BE ACCEPTED</p><p>REFRACTION IN DIOPTRES COLOUR VISION</p><p>RIGHT EYE LEFT EYE ARE YOU COLOUR BLIND?</p><p>HAS THERE BEEN EYE SURGERY (E.G. REFRACTIVE SURGERY) OR AN EYE TRAUMA: If yes please explain</p><p>VISION: ADDITIONAL INFORMATION IF APPLICABLE </p><p>HEARING: </p><p>DO YOU HAVE A </p><p>SPEECH IMPAIRMENT OTHER:</p><p>8. KNOWLEDGE OF LANGUAGES MOTHER TONGUE </p><p>UNDERSTANDING SPEAKING WRITING Other Languages Listening Reading Spoken Spoken Please see below Interaction Production Common European Framework</p><p>Levels: A1/A2: Basic user - B1/B2: Independent user - C1/C2: Proficient user COMMON EUROPEAN FRAMEWORK OF REFERENCE FOR LANGUAGES </p><p>9. REFERENCES : PLEASE GIVE THE NAMES AND ADDRESSES OF THREE PERSONS NOT RELATED TO YOU, WHO KNOW YOU PROFESSIONALLY AND/OR PERSONALLY.</p><p>FULL NAME CONTACT TELEPHONE NO. OR EMAIL ADDRESS OCCUPATION OR PROFESSION (i) </p><p>(ii) </p><p>(iii) </p><p>- 2 - C o n f i d e n t i a l</p><p>10. EDUCATION AND TRAINING GIVE BRIEF DETAILS OF FORMAL EDUCATION SINCE AGE 12. GIVE THE TITLES OF STUDIES, DIPLOMAS, CERTIFICATES ETC. IN THE ORIGINAL LANGUAGE. PROVIDE COPIES OF RELEVANT DOCUMENTS . STATE FINAL SUBJECTS STUDIED AND RESULTS/GRADES OBTAINED. USE A SEPARATE SHEET OF PAPER AS REQUIRED. STUDENTS IN THEIR FINAL YEAR MUST PROVIDE DOCUMENTARY AND VALID PROOF THAT THERE IS A REASONABLE CHANCE OF THEM SUCCEEDING IN THEIR EXAMINATIONS. MILITARY AND ASSISTANT AIR TRAFFIC CONTROLLERS MUST STATE THE LICENCES THEY HAVE OBTAINED AND THE DATES.</p><p>HIGHER SECONDARY EDUCATION (NON-UNIVERSITY) </p><p>NAME OF ESTABLISHMENT CERTIFICATES, DIPLOMAS AND/OR YEARS (FROM ... TO…) NATURE OF STUDIES QUALIFICATIONS OBTAINED (FULL-TIME, EVENING, ETC.)</p><p>UNIVERSITY EDUCATION </p><p>NAME OF UNIVERSITY CERTIFICATES, DIPLOMAS AND/OR YEARS (FROM ... TO ... ) NATURE OF STUDIES QUALIFICATIONS OBTAINED (FULL-TIME, EVENING, ETC.)</p><p>11. PROFESSIONAL ACTIVITY / STUDENT HOLIDAY JOBS: START WITH YOUR PRESENT EMPLOYMENT, AND HIGHLIGHT ANY POSITION RELATED TO ATC OR AVIATION. STATE TITLE OR FUNCTION IN THE ORIGINAL LANGUAGE OF YOUR EMPLOYER. USE A SEPARATE SHEET OF PAPER FOR ADDITIONAL PREVIOUS EMPLOYMENT IF REQUIRED.</p><p>PRESENT OR MOST RECENT EMPLOYMENT</p><p>NAME AND FULL ADDRESS OF EMPLOYER </p><p>DATE FROM TO </p><p>JOB TITLE</p><p>DESCRIPTION OF TASKS </p><p>(FURTHER DETAILS MAY BE PROVIDED </p><p>ON A SEPARATE SHEET)</p><p>- 3 - C o n f i d e n t i a l</p><p>PREVIOUS EMPLOYMENT</p><p>NAME AND FULL ADDRESS OF EMPLOYER </p><p>DATE FROM TO </p><p>JOB TITLE</p><p>DESCRIPTION OF TASKS </p><p>(FURTHER DETAILS MAY BE PROVIDED </p><p>ON A SEPARATE SHEET)</p><p>12. TIME SPENT ABROAD (OTHER THAN SHORT HOLIDAYS)</p><p>COUNTRY YEARS (FROM ... TO…) REASON </p><p>13. INTERESTS: A) WHAT ARE YOUR MAIN INTERESTS OR COMMITMENTS OUTSIDE YOUR WORK OR STUDIES?</p><p>B) IF YOU HAVE ANY FLYING EXPERIENCE AS A PILOT, PLEASE DETAIL TYPES OF AIRCRAFT, NUMBER OF HOURS FLOWN AND LICENCE HELD.</p><p>14. AVAILABILITY: WHEN WOULD YOU BE ABLE TO START A TRAINING COURSE IF ONE WAS OFFERED?</p><p>- 4 - C o n f i d e n t i a l</p><p>15. GENERAL QUESTIONS: YES NO HAVE YOU PREVIOUSLY APPLIED FOR EMPLOYMENT WITH EUROCONTROL?</p><p>WHEN? FOR WHICH POST? </p><p>HAVE YOU TAKEN ANY SELECTION TESTS FOR AN ATC JOB WITH THE CIVIL OR YES NO MILITARY AUTHORITIES IN YOUR OWN COUNTRY? IF SO,</p><p>YES NO  WAS IT THE EUROCONTROL FEAST TEST PACKAGE</p><p>SUCCESSFUL UNSUCCESSFUL  WERE THE RESULTS?</p><p>YES NO  HAVE YOU ALREADY STARTED A TRAINING COURSE WITH THEM?</p><p> IF SO, WHEN WAS THAT COURSE HELD? DATE:</p><p>YES NO  DID YOU COMPLETE THE FULL COURSE OF TRAINING?</p><p> IF YOU DID NOT COMPLETE THE TRAINING, PLEASE EXPLAIN WHY:</p><p>16. USING A SEPARATE SHEET OF PAPER AS REQUIRED, PLEASE ANSWER THE FOLLOWING QUESTIONS AND EXPLAIN IN ENGLISH, AND IN YOUR OWN WORDS:</p><p>A) WHAT ARE THE DUTIES/RESPONSIBILITIES OF A CONTROLLER?</p><p>B) WHY DO YOU THINK YOU WOULD BE A GOOD CONTROLLER?</p><p>C) </p><p>WHY DO YOU WANT TO BECOME AN AIR TRAFFIC CONTROLLER?</p><p>17. HOW DID YOU LEARN OF THIS COMPETITION? INTERNET WHICH SITE: NEWSPAPER (SPECIFY) OTHER (SPECIFY) </p><p>- 5 - C o n f i d e n t i a l</p><p>DECLARATION</p><p>(WHICH MUST BE DATED AND AGREED BY THE CANDIDATE)</p><p>I, THE UNDERSIGNED, DECLARE THAT THE INFORMATION PROVIDED ABOVE IS, TO THE BEST OF MY KNOWLEDGE, TRUE AND COMPLETE.</p><p>- I UNDERTAKE TO PRODUCE, ON REQUEST, THE ORIGINALS OF ALL THE DIPLOMAS AND/OR CERTIFICATES MENTIONED ABOVE.</p><p>- I AGREE TO UNDERGO THE REQUIRED MEDICAL EXAMINATIONS, IF SELECTED, AND ACCEPT THE CONCLUSIONS REACHED BY THE AGENCY’S MEDICAL ADVISER.</p><p>- I DECLARE THAT I HAVE NO OBJECTION TO AN INVESTIGATION BEING CONDUCTED BY THE COMPETENT AUTHORITIES OF THE STATE OF WHICH I AM A NATIONAL, WITH A VIEW TO THE ISSUE OF A CERTIFICATE OF SECURITY CLEARANCE WHICH IS REQUIRED FOR EMPLOYMENT AS A STUDENT CONTROLLER WITH EUROCONTROL. I ACCEPT THAT IF I AM SELECTED FOR TRAINING, MY APPOINTMENT WILL BE CONDITIONAL ON THE ISSUANCE OF SUCH A CLEARANCE, AND THAT I MAY BE SUBJECT TO DISMISSAL IN THE EVENT OF ITS REFUSAL.</p><p>Please check this box to agree with the above statement </p><p>Date: </p><p>Name: </p><p>PLEASE NOTE THAT COMPLETED APPLICATIONS CANNOT BE RETURNED TO CANDIDATES AND, IF UNSUCCESSFUL, WILL BE DESTROYED.</p><p>- 6 -</p>