(1) State of licence issue:

(2) Medical certificate applied for: class 1 ☐ class 2 ☐ LAPL ☐

class 3 ☐

(3) Surname:

(4) Previous surname(s):

(12) Application Initial ☐

Revalidation/Renewal ☐

(5) Forenames:

(6) Date of birth (dd/mm/yyyy):

(7) Sex

Male ☐

Female ☐

(13) Medical certificate/EAMR ID number:

(8) Place and country of birth:

(9) Nationality:

(14) Type of licence applied for:

(10) Permanent address:

Country:

Telephone No.:

Mobile No.:

e-mail:

(11) Postal address (if different)

Country:

Telephone No.:

(15) Occupation (principal)

(16) Employer

(17) Last medical examination

Date:

Place:

Completed: No ☐ Yes ☐

(18) Aviation licence(s) held (type):

Licence number:

State of issue:

(19) Any Limitations on Licence/ Medical Certificate No ☐ Yes ☐

Details:

(20) Have you ever had an aviation medical certificate denied, suspended or revoked by any licensing authority?

No ☐ Yes ☐ Date: Country:

Details:

(21) Flight time hours total:

(22) Flight time hours since last medical:

(23) Aircraft class /type(s) presently flown:

(24) Any aviation accident medical event whilst exercising the privileges of the licence since the last medical examination?

No ☐ Yes ☐ Date: Place:

Details:

(25) Current/intended pilot activity:

Commercial ☐ Non-commercial ☐ Other …………..

Single-pilot ☐ Multi-pilot ☐

(26) Current/intended ATC activity:

ADI ☐ APS ☐ ACS ☐ ADV ☐ APP ☐ ACP ☐

(27) Do you drink alcohol? ☐ No ☐ Yes, state average weekly amount:

Do you use drugs? ☐ No ☐ Yes, state the type:

(28) Do you currently use any medication?

No ☐ Yes ☐ State drug, dose, date started and why:

(29) Do you smoke tobacco? ☐ No, never ☐ No, date stopped:

☐ Yes, state type and amount:

Yes

No

Yes

No

Yes

No

Family history of:

Yes

No

101 Eye trouble/eye operation

112 Nose, throat or speech disorder

123 Malaria or other tropical disease

170 Heart or vascular disease

102 Spectacles and/or contact lenses ever worn

113 Head injury or concussion

124 A positive HIV test

171 High blood pressure

114 Frequent or severe headaches

125 Sexually transmitted disease

172 High cholesterol level

103 Spectacle/contact lens prescriptions change since last medical exam.

115 Dizziness or fainting spells

126 Sleep disorder/ apnoea syndrome

173 Epilepsy

116 Unconsciousness for any reason

127 Musculoskeletal illness/impairment

174 Mental illness or suicide

104 Hay fever, other allergy

117 Neurological disorders; stroke, epilepsy, seizure, paralysis, etc

128 Any other illness or injury

175 Diabetes

105 Asthma, lung disease

129 Admission to hospital

176 Tuberculosis

106 Heart or vascular trouble

118 Psychological/ psychiatric trouble of any sort

130 Visit to medical practitioner or mental health specialist since last medical examination

177 Allergy/ asthma/eczema

107 High or low blood pressure

178 Inherited disorders

108 Kidney stone or blood in urine

119 misuse of psychoactive substances

131 Refusal of life insurance

179 Glaucoma

109 Diabetes, hormone disorder

120 Attempted suicide or self-harm

132 Refusal of aviation licence

Females only:

110 Stomach, liver or intestinal trouble

121 Motion sickness requiring medication

133 Medical rejection from or for military service

150 Gynaecological, menstrual problems

111 Deafness, ear disorder

122 Anaemia / Sickle cell trait/other blood disorders

134 Award of pension or compensation for injury or illness

151 Are you pregnant?

(30) Remarks:

(31) Declaration: I hereby declare that I have carefully considered the statements made above and to the best of my belief they are complete and correct and that I have not withheld any relevant information or made any misleading statements. I understand that, if I have made any false or misleading statements in connection with this application, or fail to release the supporting medical information, the licensing authority may refuse to grant me a medical certificate or may withdraw any medical certificate granted, without prejudice to any other action applicable under national law.

I hereby declare that I have been informed and I understand that all information provided to my AME contained in this report and its attachments and all information which is provided to my licensing authority and that relates to me, may be released to the medical assessor of my licensing authority, other health professionals and medical administration staff as part of the aero-medical assessment process and to the medical assessor of the competent authority of my AME, recognising that these documents or electronically stored data are to be used for the completion of an aero-medical assessment and for oversight purposes, providing that I or my physician may have access to them in accordance with national law. Medical confidentiality will be respected at all times.

NOTIFICATION OF DISCLOSURE OF PERSONAL DATA: I hereby declare that I have been informed and I understand that the data contained in my medical certificate in accordance with point ARA.MED.130, or point ATCO.AR.F.005 of Regulation (EU) 2015/340 if applicable, may be electronically stored and made available to my AME in order to provide historical data required in point MED.A.035(b)(2)(ii)/(iii) or, if applicable, points ATCO.MED.A.035(b)(2)(ii) or ATCO.MED.A.035(b)(2)(iii), and to the medical assessors of the competent authorities of the Member States in order to facilitate the enforcement of point ARA.MED.150(c)(4).

--------------------------------------- ------------------------------------------------ --------------------------------------------

Date Signature of applicant Signature of AME/(GMP)/ (medical assessor)

1. LICENSING AUTHORITY:

State name of country that has issued the pilot or ATCO licence or where a licence has not been issued, the country where the applicant intends to apply for a licence.

17. LAST APPLICATION FOR A MEDICAL CERTIFICATE:

State date (day, month, year) and place (town, country)
Initial applicants state ‘NONE’.

2. MEDICAL CERTIFICATE APPLIED FOR:

18. LICENCE(S) HELD (TYPE):

Tick appropriate box representing the type of medical certificate applied for, e.g. class 1, class 2, class 3 or LAPL.

State type of licence(s) held.

Enter licence number and State of issue.

If no licences are held, state ‘NONE’.

3. SURNAME:

State surname/family name.

19. ANY LIMITATIONS ON THE LICENCE(S)/MEDICAL CERTIFICATE:

Tick appropriate box and give details of any limitations on your licence(s)/medical certificate, e.g. vision, colour vision, safety pilot, etc.

4. PREVIOUS SURNAME(S):

If your surname or family name has changed for any reason, state previous name(s).

20. MEDICAL CERTIFICATE DENIAL, SUSPENSION OR REVOCATION:

Tick ‘YES’ box if you have ever had a medical certificate denied, suspended or revoked.

If ‘YES’, state date (dd/mm/yyyy) and country where it occurred.

5. FORENAME(S):

State first and middle names (maximum three).

21. FLIGHT TIME TOTAL:

State total number of hours flown.

6. DATE OF BIRTH:

22. FLIGHT TIME SINCE LAST MEDICAL:

Specify in order dd/mm/yyyy.

State number of hours flown since your last medical examination.

7. SEX:

23. AIRCRAFT CLASS/TYPE(S) PRESENTLY FLOWN:

Tick appropriate box.

State name of principal aircraft flown, e.g. Boeing 737, Cessna 150, etc.

8. PLACE AND COUNTRY OF BIRTH:

State town and country of birth.

24. ANY AVIATION ACCIDENT OR MEDICAL EVENT WHILST EXERCISING THE PRIVILEGES OF THE LICENCE SINCE THE LAST MEDICAL EXAMINATION:

If ‘YES’ box ticked, state date (dd/mm/yyyy) and country of occurrence and provide details.

9. NATIONALITY:

25. CURRENT/INTENDED PILOT ACTIVITY:

Please tick the appropriate box regarding the current/intended activity during the following certification period:

State name of country of citizenship

· Commercial, non-commercial or other (for other, please specify the type of operation)

· Single-pilot or multi-pilot

10. PERMANENT ADDRESS:

26. CURRENT/INTENDED ATC ACTIVITY::

State permanent postal address and country. Enter telephone area code as well as telephone number.

Please tick the appropriate box regarding the current/intended activity during the following certification period e.g. ADI, APS, ACS.

11. POSTAL ADDRESS (IF DIFFERENT):

27. DO YOU DRINK ALCOHOL OR USE DRUGS?

If different from permanent address, state full current postal address including telephone number and area code. If the same, enter ‘SAME’.

Tick applicable box. If yes, state weekly alcohol consumption e.g. 2 of litres beer.

12. APPLICATION:

28. DO YOU CURRENTLY USE ANY MEDICATION?:

Tick appropriate box.

If ‘YES’, give full details - name, how much you take and when, etc.

Include any non-prescription medication.

13. MEDICAL CERTIFICATE/EAMR ID NUMBER:

29. DO YOU SMOKE TOBACCO?

State medical certificate number allocated to you by the licensing authority/EAMR ID unique number

Initial applicants enter ‘NONE’.

Tick applicable box. Current smokers state type (cigarettes, cigars, pipe) and amount (e.g. 2 cigars daily; pipe – 1 oz. weekly)

14. TYPE OF LICENCE APPLIED FOR:

30. GENERAL AND MEDICAL HISTORY

All items under this heading, from number 101 to 179 inclusive, should have the answer ‘YES’ or ‘NO’ ticked. You should tick ‘YES’ if you have ever had the condition in your life and describe the condition and approximate date in the remarks section (30). All questions asked are medically important even though this may not be readily apparent.

Items numbered 170 to 179 relate to immediate family history, whereas items numbered 150 to 151 should be answered by female applicants only.

Do not report occasional common illnesses such as colds.

State type of licence applied for from the following list:

Airline Transport Pilot Licence*

Multi-Pilot Licence*

Commercial Pilot Licence/Instrument Rating*

Commercial Pilot Licence*

Private Pilot Licence/Instrument Rating*

Private Pilot Licence*

Sailplane Pilot Licence

Balloon Pilot Licence

Light Aircraft Pilot Licence*

Air Traffic Controller Licence

Other – Please specify

*Please specify whether Fixed Wing / Rotary Wing / Both

15. OCCUPATION (PRINCIPAL):

Indicate your principal employment.

16. EMPLOYER:

If principal occupation is pilot, then state employer’s name or if self-employed, state ‘self’.

31. DECLARATION AND NOTIFICATION OF DISCLOSURE OF PERSONAL DATA:

Do not sign or date these declarations until indicated to do so by the AME/GMP who will act as witness and sign accordingly.