CIVIL AVIATION AUTHORITY CZECH REPUBLIC

APPLICATION FORM FOR CHANGE OF COMPETENT AUTHORITY - TRANSFER PART-FCL, PART-BFCL OR PART-SFCL LICENCE

Please fill in on the computer, sign it and deliver it together with attachments to address: Úřad pro civilní letectví, K letišti 1149/23, 160 08 Praha 6, Czech Republic / data box: v8gaaz5

Part A: Applicant details:

Full Name (LAST and first names):
Date and Place of Birth:
Permanent Address:
Postal Address:
E-mail:	Mobile:
Identity Card Number (Czech citizens):	Passport Number (foreign nationals):

Part B: I am a holder of this pilot licence:

Current competent authority:
Future competent authority: Civil Aviation Authority Czech Republic, K letišti 1149/23, 160 08 Praha 6, Czech Republic
Type and Number of the Part-FCL license (aeroplanes):
Type and Number of the Part-FCL license (helicopter):
Type and Number of the Part-BFCL license (balloons):
Type and Number of the Part-SFCL license (sailplanes):
Class and Number of the latest Part-MED medical certificate:

Part C: Attachments to the application (copies):

1. Passport (foreign nationals) or identity card (Czech citizens) 2. Part-FCL / Part BFCL / Part SFCL Pilot licence(s) 3. Latest issued Part-MED Medical certificate

Part D: Declaration and consent:

I hereby apply for a change of competent authority from my current competent authority to the future competent authority. To that end, I consent to a transfer of medical records, including the transfer of medical records and associated exchange of information between the current and future competent authorities. I apply for transfer of all my licences issued in accordance with Regulations (EU) No 1178/2011, (EU) 2018/395, and (EU) 2018/1976 within the different categories and I consent with associated exchange of information between the current and future competent authorities. I will immediately surrender my current licences/certificates and medical certificate to the future competent authority upon receiving the ‘new’ licences/certificates and medical certificate. I understand that the current competent authority remains my competent authority until I have received the new licences/certificates and medical certificate, as applicable, issued by the future competent authority. I hereby declare that I have not submitted any other request to another competent authority than the future competent authority as indicated above. I declare that the information provided on this application form is true, complete, and correct. Any incorrect information on this form or non-compliance with the essential requirements of Annex IV to the Basic Regulation or with the requirements of Regulations (EU) No 1178/2011, (EU) 2018/395, and (EU) 2018/1976 could disqualify the applicant from having his records transferred from the current to the future competent authority. I am aware that transferred pilot licence is not send by post and will be only handed over to applicant personally after showing the original identity card (Czech citizens) or passport and a document proving residence (foreign nationals). I agree to immediately surrender my current licences and medical certificate to the Civil Aviation Authority Czech Republic upon receiving the Czech licence and medical certificate.
Place:	Date:	Signature of Applicant:

Part E: Fee:

1.000,- CZK, Account No: 3711-3727061 / 0710 Variable symbol: on request IBAN: CZ48 0710 0037 1100 0372 7061 SWIFT: CNBACZPP