International Civil Aviation Organization Nomination Form

Training activity title:	Airport Security Supervisors Course	Dates:	4 to 13 June 2018
Training Activity Location:	Aviation Security Training Centre (ASTC), Port-of-Spain, Trinidad and Tobago

PART 1 (PLEASE PRINT)

Nominee’s Name:
M	F
(Surname)	(First name)	(Middle name)	Sex
State/Territory/International Org.
Mailing address:
Phone # with country code:
E-mail address:
Fax # with country code

Aviation background (check correct one):

CAA (State or Regulatory)	Airport	Airline	Ground services
Catering company	Cargo	Mail	Aviation Security consultant

Law enforcement or security background (check correct one):

Private security	Military	Police	Other:

AVSEC Background:

No. of years operational experience:
Duties:

1. Current Job Title:	No. of Years:
Supervisor’s name and email address:
Brief description of daily duties and responsibilities:
No. of staff supervised as part of your duties:

2.	AVSEC training courses completed: (local, regional or international)

Title of course	Year

Nominee's statement

I (name)	undertake to:

1.	conduct myself at all times in a professional manner in keeping with my status as a participant in this training activity;

2.	refrain from engaging in political, commercial or other activity detrimental to the host country or ICAO; and

3.	participate fully in the training activity, including group discussions, exercises and homework assignments

I hereby acknowledge that:

1.	I am capable of writing and speaking in the language in which the training activity will be conducted; and

2.	all information I have provided is true and correct.

Nominee’s Signature:	Date:

PART 2 (PLEASE PRINT)

Sponsoring Organization:	nominates:
to attend the above mentioned.
(Surname)	(First name)	(Middle name)

ICAO sponsored training activity and in doing so, certifies that:

1.	all information provided in this application is verifiable upon request;

2.	it will be responsible for costs associated with transport to and from the training activity, lodging, any meals not provided by the Aviation Security Training Centre (ASTC), and other incidental costs;

3.	the nominee is medically fit and in possession of medical insurance coverage for any sickness or medical emergency that may arise during the above training activity;

4.	the nominee meets any prerequisite for this training activity and/or is part of the “target” population sought by ICAO, as outlined in the invitation letter;

5.	the nominee is currently, or will be within the next 90 days, assigned to a position that reflects the objectives of the training activity; and

6.	the nominee will arrive for the beginning of the training activity and will be available for the entire event.

(Signature of authorizing authority)	(Printed name of authorizing authority)
(Title of authorizing authority)	(Date)

AFFIX OFFICIAL SEAL OR STAMP