LICENCE VERIFICATION FORM

It is required that this form is 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 licences/certificates (including restriction(s)) and corresponding licences/certificates numbers[30]*

e.g. PPL(A) — UN country code.FCL.xxx — no valid ratings

or SPL — UN country code.FCL.xxx

3

Licence issue date and expiry date (if applicable)

Issue PPL(A): xx/xx/xxxx

Issue SPL: xx/xx/xxxx

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

(as on the licence)

7

Contact details:

email and

phone number.

e.g.

[email protected]

+(country code) xxxxxxxxxx

8

Nationality

Country

9

Issuing authority (conditions under which the licence was issued, where necessary)

Country and authority

10

Valid and non-expired ratings/privileges and certificates held

(Type/class/instrument/additional ratings and instructor/examiner certificates)

Note: indicate all applicable restrictions and extensions.

Ratings and certificates

Valid until (dd/mm/yyyy)

e.g. TMG (Sailplane)

xx/xx/xxxx

e.g. FI (Sailplane)

with extensions for TMG and FI

xx/xx/xxxx

11

Expired ratings and certificates held

(Type/class/instrument/additional ratings and instructor/examiner certificates)

Note: indicate all applicable restrictions and extensions.

Ratings and certificates

Valid until (dd/mm/yyyy)

e.g. TMG (Aeroplane)

xx/xx/xxxx

12

Remarks, i.e. special endorsements relating to limitations, restrictions, or endorsements for privileges

(e.g. language proficiency level and validity (English, others))

Special endorsements

Language

Level

Validity (dd/mm/yyyy)

13

Details on completion of theoretical-knowledge or flight instruction, theoretical-knowledge examination or skill test in other Member States, if applicable (e.g validity of the ATPL theoretical knowledge)

e.g. IR theory valid until xx/xx/xxxx

14

Past or pending enforcement action[31]

Yes ☐ No ☐

(If yes, please give details on a separate page.)

I, ____________________________________________ certify that the details entered on this information form are true, complete, and correct.

For any comments, please use the space provided below or on the next page, and tick here: ☐

Authority:_______________________________________________________________________________

Contact details:_______________________________ Position:____________________________________

Signature:____________________________ Stamp/seal:__________________ Date:__________________

Comments: