CIVIL AVIATION AUTHORITY CZECH REPUBLIC

Consent with the change of information

Part A: Applicant details:

Full Name (LAST and first names):
Date and Place of Birth:
Permanent Address:
Postal Address:
E-mail:	Mobile:

Part B: Declaration and consent:

I hereby declare, I have applied for: conversion validation Of the following pilot licence:
Type of licence: (e.g. SPL, PPL, CPL, ATPL etc.)	Licence No.:	Competent authority (State of licence issue):
Type of medical certificate: (e.g. Class 1, Class 2, etc.)	Certificate No.:	Competent authority (where the medical records are held):
I hereby consent with associated exchange of information between Civil Aviation Authority Czech Republic and above named competent authorities related to: - My pilot licence type, privilege, expiration date and related information; - Pilot licence endorsements - ratings and certificates, its validity and restrictions and related information; - Level of English language proficiency and expiration date; - The class and validity of Medical certificate; - Whether the licence or certificate is subject to exception, restriction, limitation, suspension or revocation.
Place:	Date:	Signature of Applicant: