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Form19 - EN - Issue3 - Version 2014

This document is an application form for an initial, amended, or renewed Part 66 Aircraft Maintenance License from the Licensing Service in Brussels. The applicant provides personal details and selects the type of application. For amendments or renewals, the applicant describes the changes being requested and encloses relevant documentation like training certificates, experience descriptions, or copies of existing licenses. The applicant also provides employer details if applicable and selects the language for the license. By signing, the applicant declares they are not holding a license from another state and understands providing inaccurate information could disqualify them. Payment information is included at the bottom.

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Tariq Hameed
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© © All Rights Reserved
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Download as PDF, TXT or read online on Scribd
116 views

Form19 - EN - Issue3 - Version 2014

This document is an application form for an initial, amended, or renewed Part 66 Aircraft Maintenance License from the Licensing Service in Brussels. The applicant provides personal details and selects the type of application. For amendments or renewals, the applicant describes the changes being requested and encloses relevant documentation like training certificates, experience descriptions, or copies of existing licenses. The applicant also provides employer details if applicable and selects the language for the license. By signing, the applicant declares they are not holding a license from another state and understands providing inaccurate information could disqualify them. Payment information is included at the bottom.

Uploaded by

Tariq Hameed
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 5

Licensing service

Rue du Progrès 56
1210 Brussels
Tel. : 02/277 43 11
[email protected] Box for Licensing Service only

APPLICATION FOR INITIAL/AMENDMENT/RENEWAL


OF PART 66 AIRCRAFT MAINTENANCE LICENCE
(PART-66 AML)

Name: First Name:

I wish to apply for (tick relevant box):

An INITIAL Part-66 licence


An AMENDMENT to my Part-66 licence
A RENEWAL of my Part-66 licence

Addition of a new (sub)category(ies)

Rating A B1 B2 B3 C

Aeroplane - turbine
Aeroplane - piston
Helicopter - turbine
Helicopter - piston
Avionics
Piston engine non-pressurised aeroplanes MTOM of ≤2000kg
Large aircraft
Aircraft other than large aircraft
I enclose:
A certificate for credits (if relevant)
A copy of certificates for my training and/or Part-66 basic knowledge exams
A detailed description of my experience in aircraft maintenance
Addition of new rating(s) for type of aircraft or aircraft group(s)
Type of aircraft (with motor type) or group B1 B2 B3 C

I enclose:

A copy of my certificates for my theory training classes in aircraft type and/or type examinations
A copy of certificates for my practical classes in aircraft type and/or my experience

A description of my experience in aircraft type maintenance (OJT) (where relevant)

DOC/L-PEL/0200-51, issue3, 1/08/2012 EASA FORM 19


www.mobilit.belgium.be
Page 1 of 5
Limitation removal
Limitation Certificate reference number

I enclose:
A copy of the certificates for corresponding conversion exams
A description of my experience with the limitation (where relevant)

Enclose national privileges beyond the application of Part-66


Aircraft or groups of aircraft that are not a part of Annex 1

National privileges

I enclose:
Proof of national certification privileges (where relevant)

DOC/L-PEL/0200-51, issue3, 1/08/2012 EASA FORM 19


www.mobilit.belgium.be
Page 2 of 5
Application for conversion of my certifying staff qualification valid in Belgium to a PART 66 licence

I currently hold the following certi-


fication staff rating:
Within the following organisation

I enclose:
A copy of my accreditation issued by the approved maintenance body

I wish for my aircraft type ratings connected to my certifying staff qualification


to be written on my Part-66 licence:

Type of aircraft (with motor type) or group B1 B2 C

I enclose
A copy of my accreditation (example: company licence) issued by the approved
maintenance body

A copy of certificates for my training classes in aircraft type and/or my experience

Please note: to be completed only for conversion of national certification privileges prior to the date of entry into force of
the Part-66 regulations and for aircraft types for which you hold certification privileges

DOC/L-PEL/0200-51, issue3, 1/08/2012 EASA FORM 19


www.mobilit.belgium.be
Page 3 of 5
Applicant's personal details:
Name:
First Name:
National register number
Place of Birth :
Date of Birth :
Nationality :
Adress
Street:
Number:
Zip Code:

Town:
Country:
Phone Number / Mobile:
E-mail:

I enclose :
A copy of my identity card or passport.

Details of the employer:


Name
Reference of the approved
maintenance body:

Adress

Street:
Number:

Town:

Zip Code:

Country:

Phone Number:

Email:

Part-66 Aircraft Maintenance Licence Details:


Licence number:

Delivery date:

Language of the Part - 66 Licence:


French [+ English]
Dutch [+ English]

DOC/L-PEL/0200-51, issue3, 1/08/2012 EASA FORM 19


www.mobilit.belgium.be
Page 4 of 5
I declare by the present that:
1. I am not holding any Part-66 Aircraft maintenance licence issued in another Member State,
2. I have not applied for any Part-66 Aircraft maintenance licence in another Member State, and
3. I never had a Part-66 issued in another Member State which was
revoked or suspended by any other Member State.

I also understand that any incorrect information could disqualify me from holding a Part-66 Aircraft
maintenance licence.
I enclose:
My current Part-66 licence (if relevant)
A copy of proof of payment

Name:

Signature: Date:

Received on

The fee amount is:


For issuing EUR 63 (valid for 2014)
for a modification EUR 31 (valid for 2014)
for a renewal EUR 31 (valid for 2014)
The amount should be paid, before the service is carried out, to the following account:

IBAN BE51 6792 0060 2262


BIC PCHQ BEBB

DOC/L-PEL/0200-51, issue3, 1/08/2012 EASA FORM 19


www.mobilit.belgium.be
Page 5 of 5

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