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you by your Country of Citizenship
20. ANY LIMITATION ON LICENCE/MEDICAL ASSESSMENT:
Tick appropriate box and provide details of any limitations on you licence(s) and/or medical
certificate(s) e.g. correcting lenses, valid day-time only, multi-pilot operations only etc.
4. FORENAMES:
State first and middle names (maximum three)
21. HAVE YOU EVER HAD AN AVIATION MEDICAL ASSESSMENT DENIED,
SUSPENDED OR REVOKED BY ANY LICENSING AUTHORITY? IF YES DISCUSS WITH
THE MEDICAL EXAMINER:
Tick ‘Yes’ if you have ever had a Medical Assessment denied, suspended or revoked, even
if temporarily. Provide the date, place and details, and discuss with the medical examiner
5. DATE OF BIRTH:
Specify in order: Day (DD), Month (MM), Year (YYYY) in numerals e.g. 22-08-
1950
22. TOTAL FLIGHT TIME (HOURS):
For pilots, state total number of hours flown in an operating capacity. Non-pilots state ‘Not
applicable’.
6. SEX
Tick appropriate box
23. FLIGHT TIME (HOURS) SINCE LAST MEDICAL EXAMINATON:
State number of hours flown in an operating capacity since last aviation medical examination
7. APPLICATION:
Tick appropriate box. Tick ‘Initial’ if this is your first application to this
licensing authority, even if you hold other similar licences issued by another
licensing authority
24. AIRCRAFT CURRENTLY FLOWN:
State the name of aircraft currently flown e.g. Boeing 737, Airbus A 330, Cessna 150 etc.
8. COUNTRY OF LICENCE ISSUE:
State issuing country of primary licence (if not initial application)
25. ANY AIRCRAFT ACCIDENT OR REPORTED INCIDENT SINCE LAST MEDICAL
EXAMINATION?
If ‘Yes’ provide details
9. CLASS OF MEDICAL CERTIFICATE APPLIED FOR:
Tick appropriate box.
26. TYPE OF FLYING INTENDED (1):
Provide details of intended flying e.g. commercial air transport, flying instruction, private.
10. TYPE OF LICENCE APPLIED FOR (if initial application):
If applying for the first issuance of a licence to this licensing authority, please
state type of licence applied for
27. TYPE OF FLYING INTENDED (2):
Tick appropriate box(es)
11. PLACE AND COUNTRYOF BIRTH:
State city/town and country of birth
28. IF YOU DRINK ALCOHOLIC BEVERAGES STATE AVERAGE WEEKLY INTAKE IN
UNITS:
State weekly intake e.g. 12 units (beer and wine)
Note: 1 unit ~ 12 g alcohol; this corresponds to the amount of alcohol in a standard (0.34L)
can or bottle of beer, a glass of wine, etc.
12. NATONALITY:
State name of country of citizenship
29. DO YOU SMOKE TOBACCO PRODUCTS?
Tick applicable box. Current smokers should state type and amount e.g. 20 cigarettes per
day; pipe, 30 grams weekly
13. OCCUPATION (principal):
State principal occupation
30. DO YOU CURRENTLY USE ANY MEDICATION INCLUDING NON-PRESCRIBED
MEDICATION?
State medications prescribed by a medical practitioner and also non-prescribed medication
e.g. herbal remedies, medications bought without prescription (“over the counter”) . If ‘Yes’
is ticked, provide details: name of medication, date treatment was commenced, daily/weekly
dose and the condition or problem for which the medication is taken..
14. PERMANENT ADDRESS:
State main place of residence, with contact details: telephone number(s) and
e-mail address
31. GENERAL AND MEDICAL HISTORY:
All items under this heading from number 101 to 149 inclusive (101 to 151 for females)
must have the answer ‘YES’ or ‘NO’ ticked. You MUST tick ‘YES’ if you have
ever had the condition in your life and describe the condition and
approximate date in the REMARKS box. All questions asked are
medically important even though this may not be readily apparent. Items
numbered 140 to 149 relate to immediate family history. Items
numbered 150 to 151 should be completed only by female applicants.
If information has been reported on a previous application form to the licensing authority
issuing the Medical Assessment applied for and there has been no change in your
condition, you may state ‘Previously Reported, Unchanged’. However, you must still tick
YES’ to the condition. Do not report occasional common illnesses such as colds
15. POSTAL ADDRESS (if different from Permanent Address)
If relevant, state postal address and telephone number
32. DECLARATION AND CONSENT TO RELEASE OF MEDICAL INFORMATION:
Do not sign or date this section until indicated to do so by the medical examiner who will act as
witness and sign accordingly
16. EMPLOYER (principal):
State principal employer
AN APPLICANT HAS THE RIGHT TO REFUSE ANY EXAMINATION AND TEST AND TO REQUEST REFERRAL TO THE AUTHORITY. HOWEVER, THIS MAY ENTAIL
　
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本文鏈接地址：Manual of Civil Aviation Medicine 1(47)