Submit the completed form to the appropriate licensing authority. You can submit the form via email, fax, or physical mail to the addresses provided by the authority. Ensure that all required fields are filled out accurately and include any necessary supporting documentation. It is advisable to keep a copy of the submitted form for your records.

There are no specific important dates for submitting this form in 2024 and 2025.

The purpose of this form is to collect necessary personal, medical, and aviation details for the issuance or renewal of an aviation medical certificate. It is a crucial document for ensuring that aviation professionals meet the health and fitness requirements set by the licensing authority. Accurate and honest completion of this form is essential for maintaining the integrity of aviation safety standards.

• 1. State of licence issue: The country or state where the aviation licence is issued.
• 2. Medical certificate applied for: The class of the medical certificate being applied for (class 1, class 2, LAPL, etc.).
• 3. Surname: Applicant's last name.
• 4. Forenames: Applicant's first and middle names.
• 5. Place and country of birth: The location and country where the applicant was born.
• 6. Permanent address: The applicant's fixed address.
• 7. Telephone No.: The applicant's phone number.
• 8. Mobile No.: The applicant's mobile phone number.
• 9. e-mail: The applicant's email address.
• 10. Aviation licence(s) held: Details of any aviation licenses held by the applicant, including license numbers and states of issue.
• 11. Date of birth: Applicant's date of birth in the format dd/mm/yyyy.
• 12. Sex: Applicant's gender.
• 13. Nationality: Applicant's nationality.
• 14. Postal address: The applicant's postal address if different from the permanent address.
• 15. Application type: Indicate whether this is an initial application or revalidation/renewal.
• 16. Reference number: A unique reference number for the application.
• 17. Type of licence applied for: The type of aviation licence the applicant is applying for.
• 18. Occupation: The applicant's principal occupation.
• 19. Employer: The name of the applicant's employer.
• 20. Last medical examination: Details of the applicant's last medical examination, including date and place.
• 21. Any Limitations on Licence/Medical Certificate: Details of any limitations imposed on the applicant's licence or medical certificate.
• 22. Denial, suspension, or revocation of aviation medical certificate: Information about any denial, suspension, or revocation of an aviation medical certificate by the licensing authority.
• 23. Flight time hours: Total flight time hours and flight time hours since last medical examination.
• 24. Aircraft class/type(s) presently flown: Details of the aircraft classes or types the applicant is currently flying.
• 25. Aviation accidents or incidents: Information about any aviation accidents or reported incidents since the last medical examination.
• 26. Type of flying intended: The intended type of flying activity (single pilot, multi pilot, etc.).
• 27. Alcohol consumption: Details about the applicant's alcohol consumption.
• 28. Medication usage: Information about any medications currently used by the applicant.
• 29. Tobacco usage: Details about the applicant's tobacco use.
• 30. General and medical history: A checklist of the applicant's medical and general history.
• 31. Family medical history: Details of any family medical history of conditions such as heart disease, high blood pressure, mental illness, etc.
• 32. Remarks: Additional remarks or information from the applicant.
• 33. Declaration: Applicant's declaration of the accuracy and completeness of the information provided.
• 34. Consent to release of medical information: Applicant's consent to the release of medical information to the relevant authorities.
• 35. Date and signature: Date of completion and signatures of the applicant and the AME/GMP witness.

Failure to submit this form may result in delays or denial of your aviation medical certificate application. Accurate and timely submission is crucial for maintaining compliance with aviation medical standards.

• Application Denial: Your application for an aviation medical certificate may be denied if this form is not submitted.
• Operational Delays: You may face operational delays and be unable to perform aviation duties without a valid medical certificate.
• Compliance Issues: Failure to submit the form may result in non-compliance with aviation medical regulations.

• 1. Initial Application: When applying for a medical certificate for the first time.
• 2. Renewal: When renewing an existing aviation medical certificate.
• 3. Medical Updates: To provide updates on medical conditions since the last examination.
• 4. Medical Certificate Revalidation: For the revalidation of an expired or soon-to-expire medical certificate.
• 5. After Medical Incidents: Following any medical incidents or conditions that could affect aviation medical fitness.