APPLICATION FORM FOR A MEDICAL CERTIRCATE - Class 1, Class 2 & LAPL

Civil Aviation Directorate

Comolete this na ... fuDv and in BLOCK CAPITALS - Refer to instructians for
(1) state of icence issue:
I P-G. L NJ o (2)
Class 1
applied b:
Class 2 D LAPLD
-
Transport Maft.J

MEDICAL IN CONFIDENCE

(3) Surname: (4) Previous suname(s):

S ti;.rrf;LL A (12) Application Initial D
Revalidlltion/ReMI (D/'
(5) Forename(s);
rri!,lYZ.GD (6) Dale °' bil1h
(dd/rnm/yyyy):-1tl""1
.I (7) Sex
Male Bir'
(13) Reference oomber:

(8) Place and country of birth: (9) Nationaity:

Female D
,~ -{'f(;Q ll46-1C\
(14) Type of icence applied for:
, I TA£. i
1 on11.1.a ITA L,J:,. tJ
(10) Pennanent address: 1 /1 -a_c,.,;sfµ- (,C:-.'?.%'C,J S (11) Postal address (if diffefent): t\'tPL (A)
EH -:1.l £P6, .!:01;, (3V1UH
Country: u.tt.
Counby: (15) Occupation (principal): PIL. '°'
Telephone No.: ,Z.yAIJ A.I rl
Telephone No .: ~ (16) Employer: OttC.
Mobile No.: O'¾-Lt-YZ"':JZ. 1
(17) Last r:lrf, ~mination:
e-mail: pu•. SANra£f\. r-1f¥l.C!>e'&nA.iL .u,n Date:Afl t.o...t
Place: <€u1t-1gutl.6H Uk
(~ 8) Aviation icence(s) held (lype): t; CA'J wt. (19) mnlatiorls on licence(s)frnedical certi1icale held
Licence number: 1 E- FC.L - Uli 6<'\~ No Yes D Detals:
State of issue: I fl C. LA.., l>

or r,ec1
(20) Have you ever had an aviation meclcal certilicate denied, suspended
by any licensing authority?
(21) time hoU's tml: (22) Flight time hours since last
meclcat
No
Details:
Yes D Date: Cotnry: 4 -6 <;o 1?,o
23) Amal classllype(s) presenlly town:

(24) Any aviation accident or reported incident since last medical

G- ,1 H ~()O I ~'lo 0
(25) Type offtying intended:
exa~tion?
No Date: Place: Ccr1rte.t'?c.1P.L
Details: (26) Present~ activity:
Single piot Mwti pilot ts/
(27) Do y o = alcohol? (28) Do you currently use any mecication?
es, amount 4. UNIT No qy' Yes D State mug, dose, date started and why:
(29) Do you smoke tobacco? LJNo, never date slopped:
state tvoe and amoWlt
General and medical history: Do you have, or have you ever had, any of the following? (Please tick). If yes, give details 81 remarks section (30).
Yes No
101 Eye trouble/eye operation
., Yes No
V h23
Yes Nn f -.a.. ,._...... of: Yes No
~12 - · lmllll or speech cilorder o r - tropical disease V
70Htatdisease
102 Spectacles anda mnlad V ~13 Head qwy o r ~ ,v 1124 A posti;e HIV -
., V 71 High blood PR!SSUre
"v
-
lenses fNel W0ffl IV
125 Sel<ually 1ransmlled disease
) 14 F,equertor"""""' - - \.I ~72HiQh~le\lel
103 Speclacle/cOnla lens 115 Dizziness or fainting 6l)l!ls V 26 Sleep disoo derlap, Kll!8 syndrome V 173 Epilepsy
p,esaiptions change since V - I/
last medical exam. 11s u ~ ror any,_,., V h271,t,..,lloolcl!lelal t/ h74 Menial._ or ouicide I,
illnessfom=....,_,.
V
104 Hay f e l l e r , - ~ 117 disDnlels;-. (I
h28Any- or qwy V 1175 Diabetes V ,_
105 Asthma. lung disee!e V eplepsy,-. BIC. h29 Admiosmtohoopilal ., h76T--,. V
106 , . _ or vascular trouble V
K18~trouble
_ da)Y9011
h3C1 Vllil ID medical practitioner since V
t,n Aletgyfasthma/e I,
107Highorlowblood_.., V
last medical exammlion
108 Kidney stone or blood in lSine ., J1_1 9 ~ - - - I/ h31 ReilSIII d lfe insunn:e
V ~78 lnherted disardets
V b-79 GlaJooma .,
109 Diabele6. hormone di6oll:ler V'h20Allempledsuicide, o r - . - h32 Reru&al d licence ..,
110stomach, liver o r ~ L,, 21 Motion sidcness requmg Iv 33 Medical rl!jecllon from or for (/
trouble r.-:arion mi""'~ &eNice s:-...- onlv:
£,,-
~22 Almemiafliictde <>el- Iv 134A- d pension or I, 1511~-
111 oeernes,;. - disader blood disattlets 001•--• fl:lrqwyor . _ ............. s
151 Ale you prei,,ant?
(30) Remarks: If previously reported and no change since, so state.
(;Lt,.,J.tG f"r~Q.il--"5 0 I :'.-&Enc..
(3 1) Declaration: I hereby declare that I haw carafuly c o ~ It~ :rtaameuts n.ade abcwe and ID the best ol ffll' belief they are corr"'918 and comict and that
I have not wtlhheld any relevant information or made any mislead11g :rtatemants. I ISldersland that. I I haw made any false or rmleadlng statements in
connection with this application, or fal to Alie- the suppo,u,g medical information. the licensing aulhorily may refuse to grant me a medical certificate or may
withdraw any medical c:ertlicalle granted, without pn,juclce ID any other action applcable under ,.tional law.

CONSENT TO REL.EASE OF MEDICAL INFORIIA110N: I hereby autharisa the ntlease of al ir1orma1ian contained in this ,eport and any or al attachments to the
AME and, where necessary, to the medical~ of ffll' licensing aulh«iy, to the medk:al assessor of the c:oq>etant aulhoriy of fflll AME and to the relevant
medical professionals for the purpose"!
corr"'91ion of an aero-ffledical ass,n ,.,. or a secondary review, recognising that these doaanents or electronically
stored data are to be used for corr"'9tion of a media-' assns::•it and will become and w i n the property of the icensqi aulhorty, providing that I or ffll'
physician may haVe IIC08SS to them according to ,.tional law. Medical ~ a l l y wil be lespec:lied at al Imes.

NOTIFICATION OF DICLOSURE OF PERSONAL DATA: _I hereby dedare that I have been informed and I understand that the data contained in my medical
certfiCate according to ARAMED.130 be eledron,c:aly sorted and made available to fflll AME in order to pn,vida hi:rtorical date required in
MEDA035(b)(2)(i)/(ii) and to the medical assessor.. of the c:orr.,._nt aulhorities of the Member Stalas in order lo faclbta the enforcement of
ARAMED.150(cX4).
!Jl ,/,L(ZL ~ 2 1 { -=-
>
~ Q ,\J
Date Sianature of applicant Sianature of AME~ical assessor,

Fonn TM/CAOI0332 lsaue 6 • August 2021 TIWISpOII Malla iol lhe Aulhorily for TralllpOII in Mala 8B1 up'by ACr XY d 2009
Page 1 dl
 CHECKLIST FOR MENTAL HEALTH

Civil Aviation Directorate

Transport Mala- Civil AYiation OiredDrate, Pantar Road, L.ija. UA 2021. Mala. Tet.+358 2555 sa:x> .11p, trq@tr;:inc;port qoy

Comolete tldo --fidlv ..... 1111 o• ncv r• o rr • • S

(I) State oflicence issue:
IILEL.f>.r,i'O
Refer to imtructioos for ~letioo
(2) M~ i : f i cate applied for:
mt \\Y '·' ,r 11hpr,:f e•'\ mt
-
Transport Malta

MEDICAL IN CONFIDENCE

Class I Class 2 Class3 D

(J)Sumame: (4) Previous sumame(s): (12) App1icaion:
sr,..t.J n;;.L1,,r-.
r!f'
(S)
11A<LC,D
(6) Date ofbirth(dd/mm/yyyy):

.A6/oli /16f(L
I (7)Sex:
Male rV
Revalidation/Reoewal
(13) Reference number:
1€:-iiEO- Z.-t-'1~,
Female D
(8) Place and count,y of birth: (9) Nationality:
H>1L l>i 0 , nti.."L..y 11N... f~j-J
(IO)Permanentaddress:
1 /A. (Z.u~<; (Ll {.C,tl}c-(:1\1'.) (11) Postal address (if different):

<6H 1.t.. !:'Pb c0)1\it3Vll.CI-I/ vie Country:

Count,y: (J. k: / Telephone No.:
Telephone No.:
Mobile No.:
E-mail:
O:J.t 8 Z. "1 'll 1
<!I:,
1.
'1/L· cwr-r;Ltpr1t,.n.kt!_ Gt-fpJL·QJf'i
(14) Licence(s) held (type): ArtLCAJ (IS) Any ~ioos on liceoce(s}'medical certificate held
Licence number: No Details:
I la - R.L. - l+t, ~C\ Yes
(16) Have y~ver had a medical certificate denied, suspended or revoked? (17) Any ~ o n accident or reported incident since last medical examination?
No No n/a D
Yes Date: Count,y: Yes D Date: Place:
Details: Details:

(18) Do you drink alcohol? (19) Do you currently use any medication?
No Yes c:V' lfyes, amount .1. Ole CJ't,/11 No 19"'
Yes State medicatico, dose. date started and why
/
(20) Do you smoke tobacco? No, Never iu,
No, Stopped D State date:
Yes State """" and amount:

...
General and medical blsliory: (Please tldi.). Hyes, pve ddalls ID. ftllUll'U sectloa (21).
Followht& ue IIOl _ _,.
v.. No !j4er to opodolht If - .,.._ below: Y.. No ~., ...._.,...,._, v.. No F - . g - IIOl •tlofa<to<y: Yes No
(Nffll'W _ . docum~at\:
Curred. work and life atreucn Paycbotic daosdm- - •L.- ofaloobol « o d a - ~ .,.
.c.;..,;;,,:., ..,,
<'
..,,
""'""'"' ..-ldioordor ~ttitnM
CopiJl! IIU1llogies uodorperiods of
psycbologicol.....,.. or_.., in tho
I/ P>yd,ooctivo modiaoxn r,... of irt«estlono,gy
pest, iDc:ludq ooolm,g advioo from
othors ,;....,;,. ochizDtypo10£ debimol
/ and weight cbooges / G'ood /
Aey difficultios with operatimol ..... -'ood dioordor ~mg probloms 7
resource managml<u (CRM)
my dillioulti.. .;,J, c,a,ployer mdlor
I/ Neurolic,stnoawolitedor..-Carm / ~ad,ifpnDOlll.laj....:idal / n..mi.. P""""' l l l d - /
other collea2:ues l!IDd .n- en disornor o.........c- /
/ l'-n..er. ag;t.a,ioo « mg!, mood / :.,,.. ....
Jntapmsoou androlariombip..._
including dillioultioswith.-...._ / i>onooalily 0£ bebavioonl -
/ Family bioaory or pyduotric disadon.
~00

/
Disorden duotoalccmolaoda- /
frimds. and won: colJooguos osvc:hoactive ~ • ) we crmismc
Deliberato IOlf-hmn aod suicide att.empl
,, ..... ..:....... ,uicido
ao o- lcu of cmtrol r......,,..,,

(21) Ccmments:

(22) Refernl to Spedalllt

(Tick as annrooriate)
y,.
No

(23) Declaratioa: I hereby cloclan, tbat I have cardiilly comidcml the - t s made above md to the beat of my belief Ibey .., oomplde md correct md tbat I have not
withheld any rclevanl infonution or made any mulcading autemmll. I undastand that, if 1 have made any f.alae or muleading autemalll in comeclion with this applicatioo, or
fail ID rcleuc the supporting medical information, the licauing audwrity may rcwse to grant me a mcdicaI ccrtificstc or may wilhdnw any medical certificate gnntcd, without
prejudice to any other action applic:able under national law.

CONSENT TO RELEASE OF MEDICAL INJ10RMATION: I hcnby authoriae lhc rclcasc of aD information OODlaincd in Ibis RpOll md any or all attachments lo the AME
d, where nec:caUIY, ID the medical uaaaor of the liccming authorily, recognising that these docummb or dcctronically atorcd data an:: ID be med for completion of a medic.al
: ...,mcnt md will become md remain the property of lhc lic:cming authority, providing that I or my physician may have acccu to them according lo national law. Medic.al
confidentiality will be respected at all bmc:s.

-~WLL ~ ,(2 2~
Date Sionature of Annl;cant Si11.naturc o" ~ 'medical assessor\
/

FOffll 1MICA[)I0370 Issue 2 Augusl 2021 Transpo,t Malla Is the Aulhcriy for Transpoll in Mala set up by ACT XY of 2009 Page 1 of2
APPLICATION FORM FOR A MEDICAL CERTIFICATE - Class 1, Class 2 & LAPL
Civil Aviation Directorate Transport Malta

Transport Mab-CiYil AYiationOirec:IDna Parar-Road. L.ija, LJA2021, Mala. Tel:+356255551XXl ,1m,; trr::mtransnoa gov mt v-,'Mvtraosoort gov mt
MEDICAL IN CONFIDENCE
All areas reau re completion
(201) Examination categOIY (202)~t (203) Weight (204) Cok>1.I' (205) Coloi. (206) Blood (207\ Pulse - restino
(cm) (kg) eye hair pressure-seated Rate Rhythm: ~
(nmHal (bpm) regular
Initial
~1- I Diastolic

------
Revalidation ~newal \~ Systolic
its
Referral
Clinical exam: Check each item
t\+-- 1'x1
NarmaL Abnormal
/2081 Head face neck seal!> (218\ Abdomen hernia liver =een
'
_,,
Narmal Abnormal

12091 Mouth throat teeth (219\ Anus rectum ..,c ....

/210\ Nose sinuses (220\ Genilo-urinarv "'1<:f1>m ..........--
-·,,,,.-
-_,,,-
-
1211 l Ears drums eardrum motility (221 \ Endacrine svstem

--
--
1212\ Eves - orbit & adnexa· visual fields .(222\ U,...,..r & lower limbs ioints
/213\ Eves - ou!lils and ooric fl.lldi (223\ Saine other musculoskelelal
12141 Eves - ocular motility; llYSl8!111lUS !224) Neuroloaic - reflexes etc.
1215) Lunas. chest breasta
12161 Heart
12171 Vascular svstem
/.,,
(225) Psvchiatric
(2261 Skin identifvin11 marks and lymphatics
.,,_
,,,.
/ {227l General s"""'mic
(228) Notes: Describe every abnormal finding. Enter applicable iem number befo~ment.
.-- 1/\.o
tar-"'-~
Visual acuity
(229) Distant llision !236\ Pmnonarv function 1'237' u---lobin
U""1neded
Specta
clas
Contact
lenses
FEV,JFVC 'If, \ >"--\ funlt)
Riahteve \'.V'{--. Corr. to
Left eve
Both eves ,. -
~/1 Corr. to
Corr. to
Abnormal D / Normal / - r m a l D

~l"b (2351 Urinalvsis Normal ~normal D

(230) /ntermecfate llision Unconacted Corrected Blood

.
Glucose Other
Yes ., No Yes No
N
Riahteve
Left eve
Both eves
-
"""
./
i..----
Accomi,anvinn . - . .

(238\ECG
(239\ Audionr.1m
Not oerformed

,/
Nonn2I
.,,. /
...
Abnormal/Comment

(231 ) Near vision Unconacted Coneded (2401 Oohthalmok>!lV

No Yes No (241) ORL (ENl) ...,........._
,/.,,
(242\ Bk>od lipids
J243\ Pulmonarv function
(244) Other /what?\
,/
1.//
-
233 Contact fen

2~\0c~
./
No
T (2471 AME
Date of birth: Reference number:
Refraction Sph Cyl Axis Add
\(y0~/1.'l~l frh t~
Ri hte e 2..~\-~'1
Left e e
(233) Colour Vision Normal Abnormal
for class: =t
certificate issued by undersigned (copy attached) for class: - -
D Unfit for class:
I Colour vision testing methodls:
_ Results:
(234) HeMing
Deferred for rwu- evaluation. If yes, why and to whom?

(when 239/241 not performed) (248) Comments, limitations

Left ear
conversational voice test {2m) ~ --\ ~
with back turned ta examiner
Audlomet
Hz 500
Ri ht
Left
249 AME deelaratlon:
1 hereby certify that I/my AME group have personally examined 1he applicant named on this aero-medical exanination report and that this
re rt with an attachment e d" m ndin com letel and correct! .
(250) Place and date: AME name and address:
Q (f- C:.)'t--rlc.'l. \._ Dr Maged Girgis AME
AME signature:
ScoUand Aeromedical, Gyleworks ·
E-mail: 34 South Gyle Cres, Edinburgh
30
Teleph~~~ 9EB mob 07717 501621 CIVIL ~VIATION DIRECTORA E
Telefax pin@scoUandaeromedical.com

Transpolt Mala Is the Aulhorily for Trwasport in Malta set up !Jr N::T XV of 2008 Paga 3of 3
 I/. Ml:MIH'111 lfrlJIJJflfWM IIUMflC.,MJ . . fll11llf0f/111'.IUI.
Authority that issued or is to issue lhe pilot licence
XIII Limitalloi:,s "'i: Class 1 single pilot
. "~!'~' IX Expiry
date
comrnerclal opera!ions
20/07/2023
Ireland ! l'J of this
catrylng passengers (dd/mm/yyyy)
certificate Class I (ddlmmlyyyy)
Transport Malta Z!ll!!ZlZ!l23
c,... 2 ldd/mmlyyyyJ
Civil Aviation Directorate Ill Cerliflcate number ZDLDZlZ0ZZ
-- ·-- ·---
Code LAPL (ddhnmlyyyy)
Direttorat ta' I-Avjazzjoni Civili
IE MED 274699 Examination date :
Oescriplion n.111n-,,
EUROPEAN UNION IV Last and first name ol holder
Advisory information Most recent Ned
ECG
20/07/2020 22/07/2025
Class 1/2/LAPL Santella Dale of Issue : (ddlmmtyyyy)
Audio I Comp, ENT 20/07/2020 Z0/07/2025
MEDICAL CERTIFICATE Marco 04/07/2022
pertaining to a Part-FCL licence
Ophthalmology N/A next
IVa Dale ol birth
Slgna\ure ol Issuing AME I medical assessor
· 16/04/1992
CERTIFIKAT MEDIKU Ml!D.A.020 0.CrNN In fflldlc:al
Jappartjeni mal-licenzja Part-FCL {1} lC<Y1COPIIJl<l!)!1.,._.1t111.,_,,.1111p~ollholllc:6'0!•>d•-.!•ll!•~01
-lieli.111 any---- INiy
VI Na\lonality
Italian
!II .,_.,.119olar,y~tn.._~l..... hl\""9hl_....,,~ICIM!tly"
This medical cenlllcale complies wllh ICAO standards, MA~E D• fltC!!IOlhoMPIIWl'fJ" ,
1:11 tB1;e0< I.It<! ••yp n.:<lflO(lor non 1"CIC<;Dllelmoo,,;"1t,onttllll!lllllc,ly lGOftlO<IIHew1lllho
1n1110,,ort,seolttoo p,!W1)9'1,ollhon~lldol>canc'o
except for the LAPL medical certificate
,,/ 30 "
p) 'ec-llN01t1y~1Urva,IDl'111!19rlrc1~11111111 •'<0t11oll"IIDl'IDl'a~h llogmMla 1y
tbl nll<ldlton, hcercaholde<1 1h1•. '""°"1,orn,n,w...,__ _ _ ,11mmora1ar:1w:oM>e<111>oy
Mariruga skont II -Part-MEO [I} h111Gll'lda<')Of'llll_,g,tlll0JIOf/llJOIOOlinn,<""poe.:IUra.
gf~L ~VIATION DIRECTORATE
VII Signature of holder : j?) haw~llllr(911Arusool11T)rl'IIOlkltoon .
Dan Certlfikal medlku /aqbel mal•lstandards tal-lCAO,
lll .,..,....,...,,,c1_,....-.,...,_.._.,...,lrlvalw'9irlca(l,ac,tp1e1fw>diln111,..._ot
Mel gllal tertlflkal medlku gllall-LAPL XI lhctlllghlcr-:
(~) M..-otllltllt11"IIIWIQ~OM~..,._,..,_~~lol..r>CIIQ<\H1 momllal
EASA Form 147 Issue 1 ~ii/t_-~ otlhallgtrl-.
(~l 1111pe!J"lmi1,
lG)h~...,t,a1111..,...mJ10hDlptlllu~clonc . 01
 '\
Ill
Authority that Issued or Is to Issue the pllol licence XIII Class 1 slngle pilot
N~\,.
limitations IX Expiry
date ~;:;,8~:'s~::~(~/mm/yyyy) 20/07/2022
Ireland ol this
ceriificate Class 1 (dd/mmtyyyy) 20/07/2022
Transport Malta
Class 2 (ddlmmlyyyy) 20/07/2026
Civil Aviation Directorate Ill Certilicale number
Code LAPL (dd/mmfyyyy) 20/07/2026
Direttorat ta' 1-Avjazzjoni Civili IE MED 274699 Examination dale : 18/07/2021
Descrip llon
Advisory Jnformalion Most recent Ne,1
EUROPEAN UNION IV Last and first namo of holder
Class ONE
..,.,,,.,,, ..,.,......
ECG 6.V/V'/&.V&,V
Santella Dn1e ol issue : (dd/mm/yyyy)
Clas,A)/LAPL Audio / Comp. ENT
,.--,,,..,,, ..v•
MEDICAL~RTIFICATE
Marco 18/07/2021 N/A
Ophthalmology
pertaining to a Part-FCL licence
IVo Onto of birth
16/04/1992
CERTIFIKAT MEDIKU MEO.A.020 DecruH In mlldlcal lltne11
Jappartjeni mal-licenzja Part-FCL ta) t k'cnoo holdor1shnll not n•erc,vi tho l"Mlof1'1Aollhot1 llool'oco ~nd 1ullllodu111ng,or
cor,~ 11..., , ma .,t,cr, lhoy
VI Nntionality Italian (1) w• • -• ol ..., dltcrNHlnlhetlr rnodlCDl hlno.. ll\at ...... 1andarui.m 1n1t11a 1DMle!y
O XO!OSCI lhoso P,Mlcgn, ,
(7) lekoor1111a anyp,o,;r,be,:l llf_,.prot1cnhndrnndo;n!IOf'l lh!ll1t1 hlullylOW1!111'J"'D ..., 1111t
This medical cerlillcate complies with ICAO standards, salOOJU1rQ.Snol thopuWO(pnollhunP1JtcnlilDlicunc:n.
except for the LAPL medical cerlificate
(3) roc:alwa My modcat, su,g.Cat or olho1 ln!a""'°"' tlwn 19 likely 10 inlllrilf• w,U, I-if\\ 111efy
Mal'lruQa skonl II-Part-MED
Den Certlflkat medlku Jaqbel mal-istanderds lal-lCAO, VII Slgna1u,eofholder: ~ b= 30 lb) In lldd~,on. licnnco hoklllf~ !lMII. Wllh0t11 nndu:, lloLl y, _,.. nmo•IMdc,.,. ndvce .....,,. .....,,
(1 ) h."WO!nlii<f)Onl'l:, a,,q,cnlop,,,11tion0t.tn " -..ipr occoum .
(;>) h11-,o~llhorr.g,iklru,.,clmtymoilr~"ll.1on ,
(3)
l'\tiel gl'lal Certlflkal mediku gl'lall-LAPL
XI CWILAVIATION DIRECTORATE lhe~ hlcraw;
("-) havo boon tu llorin;lromartr~r.caniair.c11 111'<'DMnQ1neapac,ty 1D 11N:1,an u1 lflGn'ltlor
ol111e nii;,1craw:
EASA Form 147 Issue 1 (5)111o p,11gnlll'11 ,
(6) h:rtoboenndm!ll" lo how,lal0<11"<1d.catetinc:,01
I') lir1lrlqUlr1 arract.-.g "'-s.