CIVIL AVIATION AUTHORITY - POLAND

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(stamp/logo of the receiver)

APPLICATION FORM FOR A MEDICAL CERTIFICATE MEDICAL IN CONFIDENCE

Complete this page fully and in block capitals - Refer to instructions pages for details

(1) State of licence issue: (2) Medical certificate applied for: class 1, class 2, LAPL, other

(3) Surname: (4) Previous surname(s): (12) Application: Initial

Revalidation/Renewal
(5) Forenames: (6) Date of birth(dd/mm/yyyy): (7) Sex: (13) Reference number:
Male
Female
(8) Place and country of birth: (9) Nationality: (14) Type of licence applied for:

(10) Permanent address: (11) Postal address (if different): (15) Occupation (principal):

(16) Employer:
Country: Country:
Telephone No.: Telephone No.: (17) Last medical examination:
Mobile No.: Date:
E-mail: Place:
(18) Aviation licence(s) held (type): (19) Any Limitations on Licence/ Medical Certificate: Yes
Licence number: No
State of issue:
Details:
(20) Have you ever had an aviation medical certificate denied, (21) Flight time hours total: (22) Flight time hours since last medical:
suspended or revoked by any licensing authority?
No (23) Aircraft class / type(s) presently flown::
Yes
Date:
Country:
Details:

(24) Any aviation accident or reported incident since last medical examination? (25) Type of flying intended: (26) Present flying activity:
No Single pilot
Yes Date: Country: Multi pilot
Details:
(29) Do you smoke tobacco? (27) Do you drink alcohol? (28) Do you currently use any medication?
No, never No No
No, date stopped: Yes, amount: Yes. State drug, dose, date started and why:
Yes, state type and amount:

General and medical history: Do you have, or have you ever had, any of the following? (Please tick).
If yes, give details in remarks section (30).
YES NO YES NO YES NO FAMILY HISTORY OF: YES NO
101 Eye trouble/eye 112 Nose, throat or speech disorder 123 Malaria or other tropical 170 Heart disease
operation disease
102 Spectacles and/or 113 Head injury or concussion 124 A positive HIV test 171 High blood pressure
contact lenses ever worn
103 Spectacle/contact lens 114 Frequent or severe headaches 125 Sexually transmitted disease 172 High cholesterol level
prescriptions change since
last medical exam.
104 Hay fever, other allergy 115 Dizziness or fainting spells 126 Sleep disorder/apnoea 173 Epilepsy
syndrome
105 Asthma, lung disease 116 Unconsciousness for any reason 127 Musculoskeletal 174 Mental illness or suicide
illness/impairment
106 Heart or vascular trouble 117 Neurological disorders; stroke, 128 Any other illness or injury 175 Diabetes
epilepsy, seizure, paralysis, etc
107 High or low blood 118 Psychological/psychiatric trouble 129 Admission to hospital 176 Tuberculosis
pressure
108 Kidney stone or blood in 119 Alcohol/drug/substance abuse 130 Visit to medical practitioner 177 Allergy/asthma/eczema
urine since last medical examination
109 Diabetes, hormone 120 Attempted suicide or self-harm 131 Refusal of life insurance 178 Inherited disorders
disorder
110 Stomach, liver or 121 Motion sickness requiring medication 132 Refusal of flying licence 179 Glaucoma
intestinal trouble
Females only:
150 Gynaecological, menstrual
problems
133 Medical rejection from or for 151 Are you pregnant?
military service
111 Deafness, ear disorder 122 Anaemia / Sickle cell trait/other 134 Award of pension or
blood disorders compensation for injury or illness

(30) Remarks: If previously reported and no change since, so state.

(31) Declaration: I hereby declare that I have carefully considered the statements made above and to the best of my belief they are complete and correct and that I have not withheld any relevant information or made any misleading statements. I understand that, if I have made any false or
misleading statements in connection with this application, or fail to release the supporting medical information, the licensi ng authority may refuse to grant me a medical certificate or may withdraw any medical certificate granted, without prejudice to any other action applicable under national law.
CONSENT TO RELEASE OF MEDICAL INFORMATION: I hereby authorise the release of all information contained in this report and any or all attachments to the AME and, where necessary, to the medical assessor of th e my licensing authority , to the medical assessor of the competent
authority of my AME and to relevant medical professionals for the purpose of completion of an aero-medical assessment or a secondary review, recognising that these documents or electronically stored data are to be used for completion of a medical assessment and will become and remain the property
of the licensing authority, providing that I or my physician may have access to them according to national law. Medical confidentiality will be respected at all times.
NOTIFICATION OF DISCLOSURE OF PERSONAL DATA: I hereby declare that I have been informed and I understand that the data contained in my medical certificate according to ARA.MED.130 may be electronically stored and made available to my AM E in order to provide historical data
required in MED.A.035(b)(2)(ii)/(iii) and to the medical assessors of the competent authorities of the Member States in order to facilitate the enforcement of ARA.MED.150(c)(4).

Date ……………………………………………………………… Signature of applicant ……………………………………………………………… Signature of AME/(GMP)/ (medical assessor) ………………………………………………………………
 Remarks

(31) Declaration: I hereby declare that I have carefully considered the statements made above and to the best of my belief they are complete and correct and that I have not withheld any relevant information or made any misleading statements. I understand that, if I have made any false or
misleading statements in connection with this application, or fail to release the supporting medical information, the licensi ng authority may refuse to grant me a medical certificate or may withdraw any medical certificate granted, without prejudice to any other action applicable under national law.
CONSENT TO RELEASE OF MEDICAL INFORMATION: I hereby authorise the release of all information contained in this report and any or all attachments to the AME and, where necessary, to the medical assessor of th e my licensing authority , to the medical assessor of the competent
authority of my AME and to relevant medical professionals for the purpose of completion of an aero-medical assessment or a secondary review, recognising that these documents or electronically stored data are to be used for completion of a medical assessment and will become and remain the
property of the licensing authority, providing that I or my physician may have access to them according to national law. Medical confidentiality will be respected at all times.
NOTIFICATION OF DISCLOSURE OF PERSONAL DATA: I hereby declare that I have been informed and I understand that the data contained in my medical certificate according to ARA.MED.130 may be electronically stored and made available to my AM E in order to provide historical data
required in MED.A.035(b)(2)(ii)/(iii) and to the medical assessors of the competent authorities of the Member States in order to facilitate the enforcement of ARA.MED.150(c)(4).

Date ……………………………………………………………… Signature of applicant ……………………………………………………………… Signature of AME/(GMP)/ (medical assessor) ………………………………………………………………