AMC2
ATCO.AR.D.003(a)(2) Change of competent authority
ED Decision
2023/011/R
SUMMARY OF MEDICAL HISTORY — FORM FOR
THE TRANSFER OF ATCO MEDICAL RECORDS
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SUMMARY OF MEDICAL HISTORY — FORM FOR THE TRANSFER
OF ATCO MEDICAL RECORDS MEDICAL CONFIDENTIALITY SHALL BE ENSURED AT ALL TIMES
AS PER POINT ATCO.MED.A.015
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Item |
Description |
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1 |
State of licence(s) issue |
Country |
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2 |
Title of licence and
corresponding serial number of the licence(s) held |
UN country code ATCO.xxx |
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3 |
Full name (Last and first names) |
LAST NAME 1, LAST NAME
2, etc. First name 1, First name
2, etc. |
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4 |
Date of birth (dd/mm/yyyy) |
dd/mm/yyyy |
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5 |
Address |
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6 |
Contact details: (a) email: (b) phone number: |
e.g. (b) +(country code) xxxxxxxxxx |
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7 |
Nationality |
Country |
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8 |
Transferring authority |
Country and authority |
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9 |
Initial medical certificate
or the first medical certificate available in the competent authority: |
Date of issue |
dd/mm/yyyy |
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Date of examination |
dd/mm/yyyy |
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Type (European Class 3,
Part ATCO.MED, or national) |
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10 |
Dates of last three revalidation/renewal
examinations (if any) |
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11 |
Limitations (if any) |
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12 |
Comments on any relevant
aspect of the applicant’s medical history or examination (if appropriate,
please enclose reports). Enclose as minimum the
examinations and investigation results as required by AMC1 ATCO.AR.D.003 Change of competent authority, point
(a). |
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Past or pending enforcement action* |
Yes o No o (If yes, please provide details on a separate page.) |
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If there is insufficient space
on this form for further information, please use an additional page.
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Certification |
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I, Dr ……………………………, medical
assessor of the (competent authority name)………………………., certify that the
details given above and on any additional pages included are true and correct. |
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Date |
Signature |
Transferring authority and
stamp/seal |
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* Item 13: Specify
whether there is a current investigation into the medical certificate and
licence, or its suspension or revocation.
[applicable from 4 August 2024 - ED Decision 2023/011/R]