DR STANLEY TENZER SENIOR AVIATION MEDICAL EXAMINER MP200

AVIATION APPLICANT DETAILS

SURNAME FIRST NAME

COUNTRY OF TOWN OF
BIRTH BIRTH
DATE OF BIRTH ID /
PASSPORT
CONTACT NO 1: CONTACT NO
2
OCCUPATION EMPLOYER

FLYING SCHOOL/
AFFILIATION
E-MAIL
PERMANENT
ADDRESS:

ANY ALLERGIES

TYPE OF CLASS OF Class 1

APPLICATION INITIAL MEDICAL
Class 2
(TICK WHICH APPLIED FOR
Class 3
APPLIES) (TICK WHICH
RENEWAL* Class 4
APPLIES)
* PREVIOUS DOCTOR:
MEDICAL
DATE OF LAST MEDICAL:

AIRCRAFT TYPE HELICOPTER TYPE OF FLYING AGRICULTURE

PRESENTLY
FLOWN AIRLINE
(TICK WHICH MULTI-ENGINE
APPLIES) CHARTER

SINGLE PLEASURE
ENGINE
MULTI-PILOT STUDENT

N/A CABIN CREW

YES
INSTRUMENT ANY KNOWN
RATING NO LIMITATIONS

1
 DR STANLEY TENZER SENIOR AVIATION MEDICAL EXAMINER MP200

VISION SPECTACLES *
CORRECTION YES *
(TICK WHICH CONTACTS *
APPLIES) NO * If yes – optometrist report to be obtained – details will be
provided

NOTE:
CAA AEROMEDICAL COMMITTEE MAY REQUEST ADDITIONAL SPECIALIST
REPORTS BASED ON THE INFORMATION PROVIDED AND IN LINE WITH THE
MEDICAL PROTOCOLS - PART 67 OF THE CIVIL AVIATION REGULATIONS
AND TECHNICAL STANDARDS –Available online

DECLARATION:

APPLICANT IS TO PROVIDE ACCURATE AND TRUE STATEMENTS AND TO

NOT WITHHOLD ANY RELEVANT INFORMATION OR TO MAKE ANY
MISLEADING STATEMENTS.

APPLICANT UNDERSTANDS THAT IF FALSE STATEMENTS ARE MADE IN

CONNECTION WITH THIS APPLICATION THE SACAA MAY REFUSE TO
GRANT THE APPLICANT WITH A MEDICAL ASSESSMENT OR MAY
WITHDRAW ANY MEDICAL ASSESSMENT GRANTED.

COMPLETED BY:

NAME
SIGNATURE

DATE