APPLICATION FORM FOR CHANGE OF COMPETENT AUTHORITY

Applicant details:

Full name

(Last and first names)

LAST NAME 1, LAST NAME 2, etc.

First name 1, First name 2, etc.

Title of licence(s)/certificate(s) (including restriction(s)) and corresponding licence(s)/certificate(s) number(s)[24]

e.g. PPL(A) — UN country code.FCL.xxx

e.g. SPL — UN country code.FCL.xxx

Current competent authority

Country and authority

Future competent authority

Country and authority

I, ________________________ (last name, first name) hereby apply for a change of competent authority from my current competent authority to the future competent authority. To that end, I consent to a transfer of medical records, including the transfer of medical records and associated exchange of information between the current and future competent authorities. I apply for transfer of all my licences issued in accordance with Regulations (EU) No 1178/2011, (EU) 2018/395, and (EU) 2018/1976 within the different categories.

I will immediately surrender my current licences/certificates and medical certificate to the future competent authority upon receiving the ‘new’ licences/certificates and medical certificate.

I understand that the current competent authority remains my competent authority until I have received the new licences/certificates and medical certificate, as applicable, issued by the future competent authority.

I hereby declare that I have not submitted any other request to another competent authority than the future competent authority as indicated above.

I have fully reviewed the [please insert reference to the current competent authority’s relevant information material] and have submitted all the necessary paperwork for my application to be considered.

I declare that the information provided on this application form is true, complete, and correct.

Any incorrect information on this form or non-compliance with the essential requirements of Annex IV to the Basic Regulation or with the requirements of Regulations (EU) No 1178/2011, (EU) 2018/395, and (EU) 2018/1976 could disqualify the applicant from having his records transferred from the current to the future competent authority.

Signature:

Date: