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AMC1 ATCO.AR.D.003(a)(1) Change of competent authority

ED Decision 2023/011/R

 

LICENCE VERIFICATION FORM

This form should be filled in and signed by the issuing competent authority of the licence being transferred.

ITEM

DESCRIPTION

 

1

State of licence(s) issue

Country

2

Title of licence

ATCO or Student ATCO

3

Licence issue date

 

4

Full name

(Last and first names)

LAST NAME 1, LAST NAME 2, etc.

First name 1, First name 2, etc.

5

Date of birth (dd/mm/yyyy)

xx/xx/xxxx

6

Address

(if indicated on the licence)

 

7

Contact details:

email:

phone number:

 

e.g.

[email protected]

+(country code) xxxxxxxx

 

8

Nationality

Country

9

Transferring competent authority 

Country and authority

10

Valid and non-expired unit, instructor and assessor endorsements held

 

Endorsements

Valid until (dd/mm/yyyy)

e.g.

EDDK APS/SRA

 

xx/xx/xxxx

e.g.

OJTI

STDI

Assessor

 

xx/xx/xxxx

11

Ratings and rating endorsements held

 

Ratings and rating endorsements

Date of first issue

(dd/mm/yyyy)

e.g.

ADI

ACS

RAD

PAR

xx/xx/xxxx

12

Remarks, i.e. licence endorsements relating to language proficiency level and validity (English, others)

Language proficiency endorsements

Language

Level

Validity (dd/mm/yyyy)

 

 

 

13

Past or pending enforcement action*

Yes o No o (If yes, please provide details on a separate page.)

* Item 13: Specify whether there is an ongoing investigation into the medical certificate and licence, or its suspension or revocation.

[applicable from 4 August 2024 - ED Decision 2023/011/R]