NOMINATION FORM
INTERNATIONAL CIVIL AVIATION ORGANIZATION
AVIATION SECURITY AUDITOR TRAINING AND CERTIFICATION COURSE
Course Location:
Dates of Course: to 2009
PART I – NOMINATION BY GOVERNMENT
Name of Sponsoring Organization:
1. Nominates Mr./Ms.
(family name) (first name) (middle name)
to attend the above-mentioned auditor training course.
2. Agrees to assume responsibility for the nominee’s transportation, accommodation and other
costs to and from the course venue.
3. Certifies that the nominee is medically fit and is in possession of medical insurance coverage to
meet expenses for any sickness or medical emergency during the above training.
4. Certifies that:
a) the nominee has complete fluency (both spoken and written) in the language of
instruction of the applicable ICAO USAP auditor training course;
b) the nominee is an aviation security subject matter expert, with a minimum of three years
operational experience in aviation security and extensive knowledge of aviation security
using Annex 17 as a reference;
c) appropriate background and screening checks have been conducted on the nominee to
verify identity and previous experience, including any criminal history, and the nominee
has been assessed as being suitable to have access to restricted documentation and for
work in security restricted areas;
d) it has evidence and/or personal knowledge of the truth of the statements contained in the
nominee's personal history form regarding the nominee's technical and specialized
training record, employment history and any auditing/technical evaluation experience;
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e) the nominee is actively employed by the Appropriate Authority of an ICAO Contracting
State in aviation security activities, and any change in this status will be notified to the
ICAO Aviation Security Audit (ASA) Section; and
f) upon successful certification, the nominee will, as far as is practicable, be made available
to ICAO by the State a minimum of once per year for at least the following two years for
the purpose of conducting ICAO USAP audits.
Signature and Approval of Appropriate Authority
Sponsoring Organization: Date:
Printed Name: Title:
Mailing
Address:
Telephone: Facsimile:
E-mail:
AFFIX OFFICIAL SEAL OR STAMP
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PART II – NOMINEE’S PERSONAL HISTORY
1. Name (in full):
2. Date of Birth: 3. Nationality:
4. Job Title:
5. Contact Work Address (for mailing purposes):
Work Telephone Number:
Home Telephone Number:
Mobile Telephone Number:
Fax Number:
E-mail:
Languages Mother tongue:
Read Write Speak
Other languages
Very Well Fairly Very Well Fairly Very Well Fairly
well Well well well well well
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AVSEC Total number of years:
Experience:
Current and previous areas of security activity and responsibility:
• Cargo and mail: Yes No • Pax/bag reconciliation: Yes No
• Catering: Yes No • Access control: Yes No
• Hold baggage: Yes No • Quality control: Yes No
• Passenger and • Contingency plan: Yes No
cabin baggage: Yes No
Scope of activity: National International
Do you manage staff (e.g. inspectors)? Yes No
6. Technical and/or Specialized Training Record:
Name and Place of Subject(s) Studied Period Diploma/Certificate
Training Institute Acquired
From To
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7. Employment Record (indicate last five years and/or last two positions):
Employer Position Last Held Period Duties/Responsibilities
(name of firm/org.)
From To
8. Courses in which you have participated as an Instructor:
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9. Computer knowledge/software:
10. International audits in which you have participated as a Team Member or Team Leader
State/Airport Dates
11. Other relevant experience/qualifications:
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12. Nominee’s Statement:
I hereby undertake to:
a) conduct myself, at all times, in a manner compatible with my status as a participant in this
course;
b) refrain from engaging in political, commercial, or any activities detrimental to the host country
and the Organization; and
c) apply my newly-acquired knowledge to further the development of the national civil aviation
security programme both in my country and internationally.
I hereby acknowledge that:
a) I have complete fluency in the spoken and written language of instruction of the course;
I certify to the best of my knowledge that all the information given above is true in all respects.
Date: Nominee’s Signature:
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