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)

SURNAME :

FORENAME(S) :

If you have name in Chinese/Japanese character, please print.

DATE OF BIRTH (DD/MM/YY) :

HEIGHT (Centimetres) : WEIGHT (Kilograms) :

POSITION APPLYING FOR ;CAPTAIN,F/O

PASSPORT DETAILS
PASSPORT NO 1 / PASSPORT NO 2
COUNTRY / COUNTRY
DATE OF ISSUE / DATE OF ISSUE
DATE OF EXPIRY / DATE OF EXPIRY
CONTACT DETAILS
PERMANENT ADDRESS / TEMPORARY ADDRESS
CITY / CITY
STATE / STATE
ZIP CODE / ZIP CODE
COUNTRY / COUNTRY
TELEPHONE / TELEPHONE
FAX NO / FAX NO
MOBILE / MOBILE
E-MAIL 1 / E-MAIL 1
E-MAIL 2 / E-MAIL 2

LICENCE

ATPL LICENSE 1 (Current Licence) / ATPL LICENSE 2
NUMBER / NUMBER
COMMAND
TYPE RATINGS / COMMAND
TYPE RATINGS
COUNTRY OF ISSUE / COUNTRY OF ISSUE
DATE OF ISSUE / DATE OF ISSUE
DATE OF EXPIRY / DATE OF EXPIRY
INSTRUMENT RATING / INSTRUMENT RATING
DATE OF EXPIRY / DATE OF EXPIRY
DATE OF LAST MEDICAL / DATE OF LAST MEDICAL
DATE OF EXPIRY OF MED / DATE OF EXPIRY OF MED

EMPLOYMENT HISTORY (If the space allowed is insufficient use a separate sheet)

FROM(MM/YY) / TO(MM/YY) / COMPANY / 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:
DATE: TIME: / NAME: DISCREPANCY(IES):
YES / NO / NOTES:
FROM(MM/YY) / TO(MM/YY) / COMPANY / 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:
DATE: TIME: / NAME: DISCREPANCY(IES):
YES / NO / NOTES:
FROM(MM/YY) / TO(MM/YY) / COMPANY / 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:
DATE: TIME: / NAME: DISCREPANCY(IES):
YES / NO / NOTES:
FROM(MM/YY) / TO(MM/YY) / COMPANY / 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:
DATE: TIME: / NAME: DISCREPANCY(IES):
YES / NO / NOTES:
FROM(MM/YY) / TO(MM/YY) / COMPANY / 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:
DATE: TIME: / NAME: DISCREPANCY(IES):
YES / NO / NOTES:

ADDENDUM

FROM(MM/YY) / TO(MM/YY) / COMPANY / 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:
DATE: TIME: / NAME: DISCREPANCY(IES):
YES / NO / NOTES:
FROM(MM/YY) / TO(MM/YY) / COMPANY / 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:
DATE: TIME: / NAME: DISCREPANCY(IES):
YES / NO / NOTES:
FROM(MM/YY) / TO(MM/YY) / COMPANY / 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:
DATE: TIME: / NAME: DISCREPANCY(IES):
YES / NO / NOTES:
FROM(MM/YY) / TO(MM/YY) / COMPANY / 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:
DATE: TIME: / NAME: DISCREPANCY(IES):
YES / NO / NOTES:
FROM(MM/YY) / TO(MM/YY) / COMPANY / 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:
DATE: TIME: / NAME: DISCREPANCY(IES):
YES / NO / NOTES:

PERIODS OF UNEMPLOYMENT

Please account for any periods of unemployment of at least 30 days

FROM(MM/YY) / TO(MM/YY) / REASON

INSTRUCTOR QUALIFICATIONS

AIRCRAFT / TRAINING QUALIFICATIONS
(Line/Base/Ground/Sim etc) / AIRLINE
FLYING EXPERIENCE
AIRCRAFT / FMS Equipped Glass Cockpit / TOTAL TIME / INSTRUCTOR
TIME / DATE OF LAST FLIGHT
(DD/MM/YY)
Yes / No / Command
Time (P1) / Co-Pilot
Time(P2)*

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: / TOTAL JET TIME*: / TOTAL B757/B767 TIME:
TTL P1: / JET P1*: / JET P2*:
TTL P2: / INSTRUMENT TIME: / EFIS:
CROSS COUNTRY TIME: / CROSS COUNTRY PIC TIME: / NIGHT FLIGHT TIME :

*Commercial Jet time only-Do not include Helicopter time

CURRENCY RECORD

TOTAL FLYING HOURS IN LAST 6 MONTHS / AIRCRAFT TYPE: / P1: / P2:
DATE OF LAST PROFICIENCY CHECK ; , A/C TYPE ; , RENEWAL ; .
DATE OF LAST INSTRUMENT RATING ; , A/C TYPE ; , RENEWAL ; .

ACCIDENTS/INCIDENTS/ATC VIOLATIONS

Give details of any A/C accidents, incidents or ATC violations in which you have been involved:

BACK GROUND INFORMATION

Have you everbeen convicted of a criminaloffence in a court of law? If yes give details.
Yes / No (If Yes, give details:)
Have you ever beenconvicted 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.

COMMUTING DETAILS

If offered position, from which country and city are you planning to commute to Japan?

If the above commuting city is outside Asia or Oceania, are you willing to relocate if necessary?
If so, where can you relocate?

EXPERIENCE OF OTHER AIRLINES APPLICATION

Have you ever applied for ANA Group Companies (Air Japan/ANA & JP Express/ANK)previously? YES NO
If yes, which company? Air Japan, ANA & JP Express ANK
Yes, I underwent screening process in/( mm / yy ) , which was successful / unsuccessful
Have you ever applied for Japanese airlines previously? YES NO
(i.e. JAL, JALways, JAL express, AirDo, Skymark, &etc) Company name :
Yes, I underwent screening process in/( mm / yy ) , which was successful / unsuccessful

DECLARATION

I certify that this application is true and correct to the best of my knowledge and that if any falsification is found this will be ground for termination of application process or agreement with written notice having immediate effect.
Signed : , Date : .
Autobiographical & Other Relevant Information
(This section should include further relevant information in regards to your application not covered in the attached application form. This information can cover such topics as; work experience, management experience, explanation for resigning from previous employers, further information on any accidents or incidents, hobbies and interests etc)
Applicant Name: / Applying For; Captain / First Officer

* JUL 2012