AMC1 ARA.GEN.360(a)(2) Change of competent authority

SUMMARY OF MEDICAL HISTORY — FORM FOR THE TRANSFER OF MEDICAL RECORDS

MEDICAL DETAILS IN CONFIDENCE

Item

Description

1

State of licence(s) issue

Country

2

Title of licence(s)/certificate(s) and corresponding serial number of licence(s) held (or national medical reference number)

e. g. PPL(A) — UN country code.FCL.xxx

or SPL — UN country code.FCL.xxx

3

Full name

(Last and first names)

LAST NAME 1, LAST NAME 2, etc.

First name 1, First name 2, etc.

4

Date of birth (dd/mm/yyyy)

xx/xx/xxxx

5

Address

6

Contact details:

email; and

phone number.

e.g.

(a)         [email protected]

(b)         +(country code) xxxxxxxxxx

7

Nationality

Country

8

Issuing authority

Country and authority

9

Initial medical certificate:

Date of issue

xx/xx/xxxx

Date of examination

xx/xx/xxxx

Type of certificate (Joint Aviation Authorities (JAR), Part-Med or national)

Class

10

Dates of last three revalidation/renewal examinations (if any)

11

Limitations (if any)

12

Comments on any relevant aspect of the applicant’s medical history or examination (if applicable, please enclose reports)

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.

13

Past or pending enforcement action[23]

Yes                 No 

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

CERTIFICATION

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.

Date

Signature

Licensing authority and stamp/seal