APPLICATION FOR INITIAL / AMENDMENT / RENEWAL OF
PART-66 AIRCRAFT MAINTENANCE LICENCE (AML) EASA FORM 19
Fill in CAPITAL letters
APPLICANT'S DETAILS:
Name: ……………………………………………………………………………………………………………….
Address: …………………………………………………………………………………………………................
Tel: ……………………………. E-mail: …………………………………………………………………………..
Nationality: …………………… Date and Place of Birth: ………………………………………………............
PART-66 AML DETAILS (if applicable):
Licence No: ………………………………….. Date of Issue: ……………………………………………………
EMPLOYER'S DETAILS:
Name: …………………………………………………………………………………………………...…………..
Address: …………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………..…
Maintenance Organisation Approval Reference: ……………………………………………………………….
Tel: ………………………………………………. Fax:…………………………………………………………...
APPLICATION FOR: (Tick relevant boxes)
Initial AML Amendment of AML Renewal of AML
Issuing a duplicate Limitation removal Endorsement of a new category
CATEGORY A B1 B2 B2L B3 C L (see below)
Aeroplane Turbine
Aeroplane Piston
Helicopter Turbine
Helicopter Piston
Avionics See system ratings below
Piston engine non-pressurised aeroplanes of MTOM of 2t and below
Complex motor-powered aircraft
Aircraft other than complex motor-powered aircraft
System ratings for B2L licence:
1. autoflight
2. instruments
3. com/nav
4. surveillence
5. airframe systems
L-licence subcategories:
L1C: Composite sailplanes
L1: Sailplanes
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L2C: Composite powered sailplanes and composite ELAI aeroplanes
L2: Powered sailplanes and ELAI aeroplanes
L3H: Hot-air balloons
L3G: Gas balloons
L4H: Hot-air airships
L4G: ELA2 gas airships
L5: Gas airships other than ELA2
TYPE ENDORSEMENTS (aircraft/engine, group, group of producer)
B…... B2 C
B…... B2 C
B…... B2 C
B…... B2 C
B…... B2 C
B…... B2 C
I wish to apply for initial / amendment of/renewal of Part-66 AML, as indicated, and confirm that the
information contained in this form was correct at the time of application.
I herewith confirm that:
1. I am not holding any Part-66 AML issued in another Member State;
2. I have not applied for any Part-66 AML in another Member State; and
3. I never had a Part-66 AML issued in another Member State which was revoked or suspended in
any other Member State.
I also understand that any incorrect information could disqualify me from holding a Part-66 AML.
Signed: …………………………………………………Name: …………………………………………………..
Date: ………………………………………………………………………………………………………………...
I wish to claim the following credits (if applicable):
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Experience credits for Part-147 training
……………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………….
Examination credits for equivalent exam certificates
……………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………….
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Please enclose all relevant certificates
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Recommendation (if applicable):
It is hereby certified that the applicant has met the relevant Part-66 maintenance knowledge and
experience requirements and it is recommended that the competent authority grants or endorses the
Part-66 AML
Signed. ………………………………………………. Name……………………………………………………
Position. ……………………………………………… Date……………………………………………………...
EASA Form 19 Issue 5
Information about holding licenses and certificates of qualification:
DATE
NAME ISSUED BY NUMBER
of issue of validity
I will collect the decision and license at the Civil Aviation Authority in Warsaw*.
at the ULC Delegation in …………………..…………………..*
* select appropriate
In a connection with the fulfillment of the information obligation referred to in Art. 13 in connection
with Art. 5 sec. 1 point a and Art. 5 sec. 2 of Regulation (EU) 2016/679 of the European Parliament
and of the Council of 27 April 2016 on the protection of individuals with regard to the processing of
personal data and on the free movement of such data, and repealing Directive 95/46 / EC (general
regulation on data protection ), I declare that I have been informed that:
1. The administrator of my personal data is the President of the Civil Aviation Authority at the
address: Warsaw 02-247, Marcina Flisa Street 2, Tel. +48225207200, E-mail
[email protected]
2. The President of the Civil Aviation Authority has appointed a Data Protection Officer, whom
I can contact in any matter regarding the processing of my personal data by sending an
e-mail to the following address: [email protected]
3. The Civil Aviation Authority processes my personal data for the purpose of examining my
application.
4. The President of the Civil Aviation Authority does not intend to transfer my personal data to
third countries and international organizations
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5. My personal data, stored in the Register of Aviation Personnel will not be destroyed, while
documents from administrative proceedings will be processed for a period of 50 years from
the end of the proceedings.
6. In a connection with the processing of personal data, I have the right to request the
administrator for:
a. access to my personal data,
b. correction my personal data,
c. deleting my personal data,
d. making limitations on the processing of my personal data,
e. object to the processing of my personal data,
f. withdraw consent to the processing of my data, which I have provided voluntarily.
7. I have the right to lodge a complaint with the supervisory authority, which is the President of
the Personal Data Protection Authority.
8. Providing personal data results from the law and my consent to processing.
9. The personal data provided by me will not be used for processing consisting in automated
decision making, including profiling.
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(date and signature of applicant)
