Send: [email protected] or Luftfartstilsynet Postboks 243 8001 BODØ Report Form on combined OPC/PC For the purpose of revalidation of a rating in accordance with FCL.740.A/FCL.740.H A. Details of the applicant State of Issue Licence number/ pers. no. (11 digits) Last name First (middle) name(s) Address Telephone Postal code and city Mobile phone E-mail adress B. Details on OPC/PC Name of AOC-holder with which OPC/PC was performed: Address: Approved by (State name of CAA): Date of OPC/PC: Aircraft type: PIC OPC/PC was performed: Simulator Aircraft IFR VFR Co-pilot CATII/III C. To be completed by the Examiner I, undersigned authorised examiner, hereby declare that I have conducted a combined OPC/PC with the above mentioned licence holder with the following result: Passed Failed Name of examiner: Examiners Authorisation No: I have entered the following details in the applicants licence: Rating Date of check Valid until Rating Date of check Valid until I have not endorsed the licence Date and signature of the Examiner: Luftfartstilsynet / CAA Norway NF-1044E ver. 2.2 04/2014 Side 1 av The test and check forms used by a Non-Norwegian examiner who have been certified by another competent authority shall have the following declaration attached. FCL.1030(b)(3)(iv) from 03 April 2014 Declaration of National procedure and requirements for Non-Norwegian Examiners I hereby declare that I, [name examiner], have reviewed and applied the relevant national procedures and requirements of the applicant’s competent authority contained in version [insert document version, i.e. 01-2014] of the Examiner Differences Document. Date Signature Print Clear all Luftfartstilsynet / CAA Norway Ver..2 04/2014 Side DY