Application Form For Aviation Medical Certificate

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CIVIL AVIATION AUTHORITY
APPLICATION FORM FOR AVIATION MEDICAL CERTIFICATE
Complete this page fully and in block capitals – Refer to instructions for completion
MEDICAL IN CONFIDENCE
(3) Surname:
(4) Previous surname(s):
Title:
(13) UK CAA Reference number:
GBR:
(5) Forenames:
(6) Date of birth:
(7) Sex
(12) Application
Initial
Revalidation
Renewal
(1) State of licence issue:
(2)
Medical certificate applied for:
1
2
(14) Type of licence applied for:
LAPL
(8) Place and country of birth:
(9) Nationality:
(15) Occupation (principal)
(10) Permanent address:
(11) Postal address (if different)
(16) Employer
(17) Last medical examination
Date:
Place:
(18) Aviation licence(s) held (type):
Licence number:
State of issue:
(500) GP Name:
(19) Any Limitations on
No
Yes
Licence(s)/Medical Certificate held
Address:
Details:
Telephone Number:
(20) Have you ever had an aviation medical certificate
No
Yes
denied, suspended or revoked by any licensing
authority? If yes, discuss with AME
Date:
Place:
Details:
(21) Flight time total:
(22) Flight time since last medical:
(23) Aircraft Class /Type(s)
presently flown:
(24) Any aviation accident or reported incident since last
No
Yes
(25) Type of flying intended:
medical examination?
Date:
Place:
Details:
(26) Present flying activity
Single pilot
Multi pilot
(27) Alcohol – state average weekly intake in units:
(29) Do you smoke tobacco?
Never
No
Yes
Date stopped:
State type, amount & number of years:
(28) Do you currently use any medication?
No
Yes
If YES, state medication, dose, date started and why
MED 160 14072015
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CAA Ref:

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