Application Form For Aviation Medical Certificate (Page 3 of 3) in pdf

INSTRUCTION PAGE FOR COMPLETION OF THE APPLICATION FORM

FOR AN MEDICAL CERTIFICATE

This application form and all attached report forms will be transmitted to the licensing authority. Medical confidentiality shall be respected at all times.

The applicant should personally complete, in full, all questions (sections) on the application form. Writing should be legible and in block capitals, using a ball-

point pen . Completion of this form by typing/printing is also acceptable. If more space is required to answer any questions, a plain sheet of paper should be

used, bearing the applicant’s name and signature, and the date of signing. T he following numbered instructions apply to the numbered headings on the

application form for a medical certificate.

Failure to complete the application form in full, or write legibly, may result in non-acceptance of the application form. The making of false or misleading

statements or withholding of relevant information in respect of this application may result in criminal prosecution, denial of this application and/or withdrawal of

any medical certificate(s) granted.

1. LICENSING AUTHORITY:

17. LAST APPLICATION FOR A MEDICAL CERTIFICATE:

State name of country this application is to be forwarded to.

State date (day, month, year) and place (town, country).

Initial applicants state ‘NONE’.

2. MEDICAL CERTIFICATE APPLIED FOR:

18. LICENCE(S) HELD (TYPE):

Tick appropriate box.

State type of licence(s) held. Enter licence

Class 1: Professional Pilot

number and State of issue. If no licences are held, state ‘NONE’.

Class 2: Private Pilot

500. GP NAME:

LAPL

Completion of this area is optional

3. SURNAME:

19. ANY LIMITATIONS ON THE

State Surname/Family name.

LICENCE(S)/MEDICAL CERTIFICATE:

Tick appropriate box and give details of any limitations on your

licence(s)/medical certificate eg, vision, colour vision, safety pilot, etc.

4. PREVIOUS SURNAME(S):

20. MEDICAL CERTIFICATE DENIAL, SUSPENSION OR REVOCATION:

If your surname or family name has changed for any reason, state

Tick ‘YES’ box if you have ever had a medical certificate denied,

suspended or revoked, even if only temporary

previous name(s).

If ‘YES’, state date (dd/mm/yyyy) and

country where occurred.

5. FORENAME(S):

21. FLIGHT TIME TOTAL:

State first and middle names (maximum three).

State total number of hours flown.

6. DATE OF BIRTH:

22. FLIGHT TIME SINCE LAST MEDICAL:

Specify in order dd/mm/yyyy

State number of hours flown since your last medical examination.

7. SEX:

23. AIRCRAFT CLASS/TYPE (S) PRESENTLY FLOWN:

Tick as appropriate.

State name of principal aircraft flown,eg Boeing 737, Cessna 150, etc.

8. PLACE AND COUNTRY OF BIRTH:

24. ANY AIRCRAFT ACCIDENT OR REPORTED INCIDENT SINCE LAST

MEDICAL EXAMINATION:

State town and country of birth.

If ‘YES’ box ticked, state Date (dd/mm/yyyy) and Country of

accident/Incident.

9. NATIONALITY:

25. TYPE OF FLYING INTENDED:

State name of country of citizenship.

State whether airline, charter, single-pilot, commercial air transport,

carrying passengers, agriculture, pleasure, etc.

10. PERMANENT ADDRESS:.

26. PRESENT FLYING ACTIVITY:

State permanent postal address and country. Enter telephone area

Tick appropriate box to indicate whether you fly as the SOLE pilot or not.

code as well as telephone number.

11. POSTAL ADDRESS (IF DIFFERENT):

27. DO YOU DRINK ALCOHOL?:

If different from permanent address, state full current postal address

Tick applicable box. If yes, state weekly alcohol consumption eg, 2 litres

of beer.

including telephone number and area code. If the same, enter ‘SAME’.

12. APPLICATION:

28. DO YOU CURRENTLY USE ANY MEDICATION?:

Tick appropriate box.

If ‘YES’, give full details - name, how much do you take and when, etc.

Include any non-prescription medication.

13. REFERENCE NUMBER:

29. DO YOU SMOKE TOBACCO?

State Reference Number allocated to you by the licensing authority

Tick applicable box. Current smokers state type (cigarettes, cigars,

Initial applicants enter ‘NONE’.

pipe) and amount (eg, 2 cigars daily; pipe - 1 oz weekly)

14. TYPE OF LICENCE APPLIED FOR:

GENERAL AND MEDICAL HISTORY

State type of licence applied for from the following list:

All items under this heading from number 101 to 179 inclusive should

Aeroplane Transport Pilot Licence

have the answer ‘YES’ or ‘NO’ ticked. You should tick ‘YES’ if you have

ever had the condition in your life

Multi-pilot Licence

and describe the condition and

Commercial Pilot Licence/Instrument Rating

approximate date in the (30) remarks box. All questions asked are

Commercial Pilot Licence

medically important even though this may not be readily apparent. Items

Private Pilot Licence/Instrument Rating

numbered 170 to 179 relate to immediate family history, whereas items

Private Pilot Licence

numbered 150 to 151 should be answered by female applicants only.

Sailplane Pilot Licence

If information has been reported on a previous application form for a

medical certificate and

Balloon Pilot Licence

there has been no change in your condition, you may state ‘Previously

Light Aircraft Pilot Licence

Reported; No Change Since’. However, you should still tick ‘YES’ to the

condition.

And whether Fixed Wing / Rotary Wing / Both

Do not report occasional common illnesses such as colds.

Other – Please specify

15. OCCUPATION:

Indicate your principal employment.

16. EMPLOYER:

31. DECLARATION AND CONSENT TO OBTAINING AND RELEASING

If principal occupation is pilot, then state employer’s name or if self-

INFORMATION:

employed, state ’self’.

Do not sign or date these declarations until indicated to do so by the AME

who will act as witness and sign accordingly.

MED 160 140715

Page 3 of 3

Instructions for completion

Application Form For Aviation Medical Certificate Page 3

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