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AMC1 ARA.GEN.360(a)(2) Change of competent authority
Available versions for ERULES-1963177438-16886
ED Decision 2020/005/R
found in: Aircrew (1178/2011) Part-FCL Part-MED Part-CC Part-ARA Part-ORA Part-DTO (Aug 2023)
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AMC1 ARA.GEN.360(a)(2) Change of competent authority ED Decision 2020/005/R SUMMARY OF MEDICAL HISTORY — FORM FOR THE TRANSFER OF MEDICAL RECORDS <table border="1" cellpadding="0" cellspacing="0" width="602"><tr><td colspan="4" width="602"><p align="center">SUMMARY OF MEDICAL HISTORY — FORM FOR THE TRANSFER OF MEDICAL RECORDS</p><p align="center">MEDICAL DETAILS IN CONFIDENCE</p></td></tr><tr><td valign="top" width="41"><p>Item</p></td><td valign="top" width="304"><p>Description</p></td><td colspan="2" valign="top" width="257"></td></tr><tr><td valign="top" width="41"><p>1</p></td><td valign="top" width="304"><p>State of licence(s) issue</p></td><td colspan="2" valign="top" width="257"><p><i>Country</i></p></td></tr><tr><td valign="top" width="41"><p>2</p></td><td valign="top" width="304"><p>Title of licence(s)/certificate(s) and corresponding serial number of licence(s) held (or national medical reference number)</p></td><td colspan="2" valign="top" width="257"><p><i>e. g. PPL(A) — UN country code.FCL.xxx</i></p><p><i>or SPL — UN country code.FCL.xxx</i></p></td></tr><tr><td valign="top" width="41"><p>3</p></td><td valign="top" width="304"><p>Full name</p><p>(Last and first names)</p></td><td colspan="2" valign="top" width="257"><p><i>LAST NAME 1, LAST NAME 2, etc.</i></p><p><i>First name 1, First name 2, etc.</i></p></td></tr><tr><td valign="top" width="41"><p>4</p></td><td valign="top" width="304"><p>Date of birth (dd/mm/yyyy)</p></td><td colspan="2" valign="top" width="257"><p><i>xx/xx/xxxx</i></p></td></tr><tr><td valign="top" width="41"><p>5</p></td><td valign="top" width="304"><p>Address</p></td><td colspan="2" valign="top" width="257"><p></p></td></tr><tr><td valign="top" width="41"><p>6</p></td><td valign="top" width="304"><p>Contact details:</p><p>email; and</p><p>phone number.</p></td><td colspan="2" valign="top" width="257"><p><i>e.g.</i></p><p><i>(a) example@example.eu</i></p><p><i>(b) +(country code) xxxxxxxxxx</i></p></td></tr><tr><td valign="top" width="41"><p>7</p></td><td valign="top" width="304"><p>Nationality</p></td><td colspan="2" valign="top" width="257"><p><i>Country</i></p></td></tr><tr><td valign="top" width="41"><p>8</p></td><td valign="top" width="304"><p>Issuing authority</p></td><td colspan="2" valign="top" width="257"><p><i>Country and authority</i></p></td></tr><tr><td rowspan="4" valign="top" width="41"><p>9</p></td><td rowspan="4" valign="top" width="304"><p>Initial medical certificate:</p></td><td valign="top" width="132"><p>Date of issue</p></td><td valign="top" width="125"><p><i>xx/xx/xxxx</i></p></td></tr><tr><td valign="top" width="132"><p>Date of examination</p></td><td valign="top" width="125"><p><i>xx/xx/xxxx</i></p></td></tr><tr><td valign="top" width="132"><p>Type of certificate (Joint Aviation Authorities (JAR), Part-Med or national)</p></td><td valign="top" width="125"></td></tr><tr><td valign="top" width="132"><p>Class</p></td><td valign="top" width="125"></td></tr><tr><td rowspan="3" valign="top" width="41"><p>10</p></td><td rowspan="3" valign="top" width="304"><p>Dates of last three revalidation/renewal examinations (if any)</p></td><td colspan="2" valign="top" width="257"></td></tr><tr><td colspan="2" valign="top" width="257"></td></tr><tr><td colspan="2" valign="top" width="257"></td></tr><tr><td valign="top" width="41"><p>11</p></td><td valign="top" width="304"><p>Limitations (if any)</p></td><td colspan="2" valign="top" width="257"></td></tr><tr><td valign="top" width="41"><p>12</p></td><td valign="top" width="304"><p>Comments on any relevant aspect of the applicant’s medical history or examination (if applicable, please enclose reports)</p><p>Please enclose at least the latest examination report and electrocardiogram (ECG). In addition, where applicable for the class of medical certification, please enclose the latest ophthalmological, ear-nose-throat (ENT), and mental health assessment reports.</p></td><td colspan="2" valign="top" width="257"></td></tr><tr><td valign="top" width="41"><p>13</p></td><td valign="top" width="304"><p>Past or pending enforcement action<a href="#_ftn23">[23]</a></p></td><td colspan="2" valign="top" width="257"><p>Yes No </p><p>(If yes, please give details on a separate page.)</p></td></tr></table> If there is insufficient space on this form for any information, please use additional pages. <table border="1" cellpadding="0" cellspacing="0" width="604"><tr><td colspan="3" valign="top" width="604"><p>CERTIFICATION</p></td></tr><tr><td colspan="3" width="604"><p>I, Dr ____________________________, as medical assessor of the (NAA name) ________________________________________________________, certify that the details given above and on any additional pages included are true, complete, and correct.</p></td></tr><tr><td valign="top" width="198"><p>Date</p></td><td valign="top" width="198"><p>Signature</p></td><td valign="top" width="208"><p>Licensing authority and stamp/seal</p></td></tr></table> --- [[23]](#_ftnref23) Item 13: specify if there is a current investigation into the medical certificate and licence, or suspension or revocation thereof.
AMC1 ARA.GEN.360(a)(2) Change of competent authority ED Decision 2020/005/R SUMMARY OF MEDICAL HISTORY — FORM FOR THE TRANSFER OF MEDICAL RECORDS <table border="1" cellpadding="0" cellspacing="0" width="602"> <tr> <td colspan="4" width="602"> <p align="center">SUMMARY OF MEDICAL HISTORY — FORM FOR THE TRANSFER OF MEDICAL RECORDS</p> <p align="center">MEDICAL DETAILS IN CONFIDENCE</p> </td> </tr> <tr> <td valign="top" width="41"> <p>Item</p> </td> <td valign="top" width="304"> <p>Description</p> </td> <td colspan="2" valign="top" width="257"> </td> </tr> <tr> <td valign="top" width="41"> <p>1</p> </td> <td valign="top" width="304"> <p>State of licence(s) issue</p> </td> <td colspan="2" valign="top" width="257"> <p><i>Country</i></p> </td> </tr> <tr> <td valign="top" width="41"> <p>2</p> </td> <td valign="top" width="304"> <p>Title of licence(s)/certificate(s) and corresponding serial number of licence(s) held (or national medical reference number)</p> </td> <td colspan="2" valign="top" width="257"> <p><i>e. g. PPL(A) — UN country code.FCL.xxx</i></p> <p><i>or SPL — UN country code.FCL.xxx</i></p> </td> </tr> <tr> <td valign="top" width="41"> <p>3</p> </td> <td valign="top" width="304"> <p>Full name</p> <p>(Last and first names)</p> </td> <td colspan="2" valign="top" width="257"> <p><i>LAST NAME 1, LAST NAME 2, etc.</i></p> <p><i>First name 1, First name 2, etc.</i></p> </td> </tr> <tr> <td valign="top" width="41"> <p>4</p> </td> <td valign="top" width="304"> <p>Date of birth (dd/mm/yyyy)</p> </td> <td colspan="2" valign="top" width="257"> <p><i>xx/xx/xxxx</i></p> </td> </tr> <tr> <td valign="top" width="41"> <p>5</p> </td> <td valign="top" width="304"> <p>Address</p> </td> <td colspan="2" valign="top" width="257"> <p></p> </td> </tr> <tr> <td valign="top" width="41"> <p>6</p> </td> <td valign="top" width="304"> <p>Contact details:</p> <p>email; and</p> <p>phone number.</p> </td> <td colspan="2" valign="top" width="257"> <p><i>e.g.</i></p> <p><i>(a) example@example.eu</i></p> <p><i>(b) +(country code) xxxxxxxxxx</i></p> </td> </tr> <tr> <td valign="top" width="41"> <p>7</p> </td> <td valign="top" width="304"> <p>Nationality</p> </td> <td colspan="2" valign="top" width="257"> <p><i>Country</i></p> </td> </tr> <tr> <td valign="top" width="41"> <p>8</p> </td> <td valign="top" width="304"> <p>Issuing authority</p> </td> <td colspan="2" valign="top" width="257"> <p><i>Country and authority</i></p> </td> </tr> <tr> <td rowspan="4" valign="top" width="41"> <p>9</p> </td> <td rowspan="4" valign="top" width="304"> <p>Initial medical certificate:</p> </td> <td valign="top" width="132"> <p>Date of issue</p> </td> <td valign="top" width="125"> <p><i>xx/xx/xxxx</i></p> </td> </tr> <tr> <td valign="top" width="132"> <p>Date of examination</p> </td> <td valign="top" width="125"> <p><i>xx/xx/xxxx</i></p> </td> </tr> <tr> <td valign="top" width="132"> <p>Type of certificate (Joint Aviation Authorities (JAR), Part-Med or national)</p> </td> <td valign="top" width="125"> </td> </tr> <tr> <td valign="top" width="132"> <p>Class</p> </td> <td valign="top" width="125"> </td> </tr> <tr> <td rowspan="3" valign="top" width="41"> <p>10</p> </td> <td rowspan="3" valign="top" width="304"> <p>Dates of last three revalidation/renewal examinations (if any)</p> </td> <td colspan="2" valign="top" width="257"> </td> </tr> <tr> <td colspan="2" valign="top" width="257"> </td> </tr> <tr> <td colspan="2" valign="top" width="257"> </td> </tr> <tr> <td valign="top" width="41"> <p>11</p> </td> <td valign="top" width="304"> <p>Limitations (if any)</p> </td> <td colspan="2" valign="top" width="257"> </td> </tr> <tr> <td valign="top" width="41"> <p>12</p> </td> <td valign="top" width="304"> <p>Comments on any relevant aspect of the applicant’s medical history or examination (if applicable, please enclose reports)</p> <p>Please enclose at least the latest examination report and electrocardiogram (ECG). In addition, where applicable for the class of medical certification, please enclose the latest ophthalmological, ear-nose-throat (ENT), and mental health assessment reports.</p> </td> <td colspan="2" valign="top" width="257"> </td> </tr> <tr> <td valign="top" width="41"> <p>13</p> </td> <td valign="top" width="304"> <p>Past or pending enforcement action<a href="#_ftn26">[26]</a></p> </td> <td colspan="2" valign="top" width="257"> <p>Yes No </p> <p>(If yes, please give details on a separate page.)</p> </td> </tr> </table> If there is insufficient space on this form for any information, please use additional pages. <table border="1" cellpadding="0" cellspacing="0" width="604"> <tr> <td colspan="3" valign="top" width="604"> <p>CERTIFICATION</p> </td> </tr> <tr> <td colspan="3" width="604"> <p>I, Dr ____________________________, as medical assessor of the (NAA name) ________________________________________________________, certify that the details given above and on any additional pages included are true, complete, and correct.</p> </td> </tr> <tr> <td valign="top" width="198"> <p>Date</p> </td> <td valign="top" width="198"> <p>Signature</p> </td> <td valign="top" width="208"> <p>Licensing authority and stamp/seal</p> </td> </tr> </table> --- [[26]](#_ftnref26) Item 13: specify if there is a current investigation into the medical certificate and licence, or suspension or revocation thereof.
##### AMC1 ARA.GEN.360(a)(2) Change of competent authority *ED Decision 2020/005/R* **SUMMARY OF MEDICAL HISTORY — FORM FOR THE TRANSFER OF MEDICAL RECORDS** <table cellpadding="7" cellspacing="0"> <col/> <col/> <col/> <col/> <tr> <td colspan="4"><p align="center"> <b>SUMMARY OF MEDICAL HISTORY — FORM FOR THE TRANSFER OF MEDICAL RECORDS</b></p> <p align="center"><b>MEDICAL DETAILS IN CONFIDENCE</b></p> </td> </tr> <tr valign="top"> <td><p align="left"> <b>Item</b></p> </td> <td><p align="left"> <b>Description</b></p> </td> <td colspan="2"><p align="left"> <br/> </p> </td> </tr> <tr valign="top"> <td><p align="left"> 1</p> </td> <td><p align="left"> State of licence(s) issue</p> </td> <td colspan="2"><p align="left"> <i>Country</i></p> </td> </tr> <tr valign="top"> <td><p align="left"> 2</p> </td> <td><p align="left"> Title of licence(s)/certificate(s) and corresponding serial number of licence(s) held (or national medical reference number)</p> </td> <td colspan="2"><p align="left"> <i>e. g. PPL(A) — UN country code.FCL.xxx</i></p> <p align="left"><i>or SPL — UN country code.FCL.xxx</i></p> </td> </tr> <tr valign="top"> <td><p align="left"> 3</p> </td> <td><p align="left"> Full name</p> <p align="left">(Last and first names)</p> </td> <td colspan="2"><p align="left"> <i>LAST NAME 1, LAST NAME 2, etc.</i></p> <p align="left"><i>First name 1, First name 2, etc.</i></p> </td> </tr> <tr valign="top"> <td><p align="left"> 4</p> </td> <td><p align="left"> Date of birth (dd/mm/yyyy)</p> </td> <td colspan="2"><p align="left"> <i>xx/xx/xxxx</i></p> </td> </tr> <tr valign="top"> <td><p align="left"> 5</p> </td> <td><p align="left"> Address</p> </td> <td colspan="2"><p align="left"> <br/> </p> </td> </tr> <tr valign="top"> <td><p align="left"> 6</p> </td> <td><p align="left"> Contact details:</p> <p align="left"> email; and</p> <p align="left">phone number.</p> </td> <td colspan="2"><p align="left"> <i>e.g.</i></p> <p align="left"> <i>(a) example@example.eu</i></p> <p align="left"><i>(b) +(country code) xxxxxxxxxx</i></p> </td> </tr> <tr valign="top"> <td><p align="left"> 7</p> </td> <td><p align="left"> Nationality</p> </td> <td colspan="2"><p align="left"> <i>Country</i></p> </td> </tr> <tr valign="top"> <td><p align="left"> 8</p> </td> <td><p align="left"> Issuing authority</p> </td> <td colspan="2"><p align="left"> <i>Country and authority</i></p> </td> </tr> <tr valign="top"> <td rowspan="4"><p align="left"> 9</p> </td> <td rowspan="4"><p align="left"> Initial medical certificate:</p> </td> <td><p align="left"> Date of issue</p> </td> <td><p align="left"> <i>xx/xx/xxxx</i></p> </td> </tr> <tr valign="top"> <td><p align="left"> Date of examination</p> </td> <td><p align="left"> <i>xx/xx/xxxx</i></p> </td> </tr> <tr valign="top"> <td><p align="left"> Type of certificate (Joint Aviation Authorities (JAR), Part-Med or national)</p> </td> <td><p align="left"> <br/> </p> </td> </tr> <tr valign="top"> <td><p align="left"> Class</p> </td> <td><p align="left"> <br/> </p> </td> </tr> <tr valign="top"> <td rowspan="3"><p align="left"> 10</p> </td> <td rowspan="3"><p align="left"> Dates of last three revalidation/renewal examinations (if any)</p> </td> <td colspan="2"><p align="left"> <br/> </p> </td> </tr> <tr valign="top"> <td colspan="2"><p align="left"> <br/> </p> </td> </tr> <tr valign="top"> <td colspan="2"><p align="left"> <br/> </p> </td> </tr> <tr valign="top"> <td><p align="left"> 11</p> </td> <td><p align="left"> Limitations (if any)</p> </td> <td colspan="2"><p align="left"> <br/> </p> </td> </tr> <tr valign="top"> <td><p align="left"> 12</p> </td> <td><p align="left"> Comments on any relevant aspect of the applicant’s medical history or examination (if applicable, please enclose reports)</p> <p align="left">Please enclose at least the latest examination report and electrocardiogram (ECG). In addition, where applicable for the class of medical certification, please enclose the latest ophthalmological, ear-nose-throat (ENT), and mental health assessment reports.</p> </td> <td colspan="2"><p align="left"> <br/> </p> </td> </tr> <tr valign="top"> <td><p align="left"> 13</p> </td> <td><p align="left"> Past or pending enforcement action<a href="#_ftn29" name="_ftnref29">[29]</a></p> </td> <td colspan="2"><p align="left"> <b>Yes ☐ No ☐</b></p> <p align="left">(If yes, please give details on a separate page.)</p> </td> </tr> </table> If there is insufficient space on this form for any information, please use additional pages. <table cellpadding="7" cellspacing="0"> <col/> <col/> <col/> <tr> <td colspan="3" valign="top"><p align="left"> <b>CERTIFICATION</b></p> </td> </tr> <tr> <td colspan="3"><p align="left"> I, Dr ____________________________, as medical assessor of the (NAA name) ________________________________________________________, certify that the details given above and on any additional pages included are true, complete, and correct.</p> </td> </tr> <tr valign="top"> <td><p align="left"> Date</p> </td> <td><p align="left"> Signature</p> </td> <td><p align="left"> Licensing authority and stamp/seal</p> </td> </tr> </table> --- [[29]](#_ftnref29) Item 13: specify if there is a current investigation into the medical certificate and licence, or suspension or revocation thereof.