24067-407 Application For Replacement Of A Medical Certificate printable pdf download

24067-407 Application For Replacement Of A Medical Certificate

Application for Replacement of Medical Certificate

Section A – Applicant Details

1. Name:

2. CAA Client No:

3. Postal Address:

4. Date of Birth:

5. Certificate Lost or Destroyed:

6. Certificate Holder’s Signature:

Class 1

Class 2

Class 3

Date:

Section B – Application

I apply under CAR 67.65 for replacement of my medical certificate, which has been damaged

Please enclose the damaged certificate and mail with this application, to the Central Medical Unit.

I apply under CAR 67.65 for replacement of my medical certificate which has been lost, stolen or destroyed

(please delete as appropriate).

Please fill in the statutory declaration below and mail this form and fee to the:

Central Medical Unit

Civil Aviation Authority

PO Box 3555, Wellington 6140

Section C – Declaration (Not if certificate is enclosed)

Form of Declaration

I, ________________________________________________, CAA Client ID ________________ solemnly and

sincerely declare that:

______________________________________________________________________________________________________

And I make this solemn declaration conscientiously believing the same to be true and by virtue of the Oaths and

Declarations Act 1957.

Signed by Applicant: _____________________________ Signature of Authorised Officer: _________________________

Declared at:

_____________________________ this ___________ day of ____________ 20_____

Person authorised to take a statutory declaration. (i.e. Justice of the Peace)

$99.00 (incl GST)

DO NOT SEND CASH

Section D – Fee for replacement is

Please enclose payment by

cheque made out to - Civil Aviation Authority or you can also make a Visa/MasterCard payment if you wish by completing

the details below. Make sure your application is completed before posting. If it is not, it will be returned to you.

I enclose my cheque

Visa

MasterCard

Name on Card:

Expiry Date:

Card Number:

Signature:

OFFICE USE ONLY

Receipt No.

Receipt Date

W/R No.

MISCMED

Page 1 of 1

24067-407

Rev 3 : Nov 2012

24067-407 Application For Replacement Of A Medical Certificate

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