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Print Form Cyprus Department of Civil Aviation PART-66 AIRCRAFT MAINTENANCE CONVERSION APPLICATION ENGINEER S LICENCE NATIONAL QUALIFICATIONS Please complete the form in BLOCK CAPITALS using black or dark blue ink APPLICANTS DETAILS DCA National Validation Number License Date of Issue Surname First name s Date of birth dd/mm/yyyy Place of Birth Nationality Permanent address Postcode Address for correspondence if different from above Telephone Number Fax Number Email address Name and address of Employer Maintenance Organisation Approval Ref. Fax No. APPLICATION In Rating A Aeroplanes Piston Helicopter Turbine Helicopter Piston B2 N/A Avionic B1 Aeroplanes Turbine SUMMARY OF EXPERIENCE Dates EASA Form 19 Aircraft Engine s and/or Equipment V2JUN2011 Description of work Page 1 of 2 DECLARATION I wish to have my National Qualifications converted to a Part-66 license 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 I never had a Part 66 AML issued in another Member State which was revoked or suspended in any other Member State.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* Signature PAYMENT METHOD SUBMISSION INSTRUCTIONS Complete Payment Form LICACC 01 Please refer to Department s official webpage for application form and details of fees required* Once your application is completed your application should be posted along with the required documentation to Please note that failure to submit all required documentation will result in the return of your application* I have submitted all required documentation please tick a Certified true copies of worksheets or logbooks b Copy of passport or other National Identity document c Original DCA National Validation. 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 I never had a Part 66 AML issued in another Member State which was revoked or suspended in any other Member State. I never had a Part 66 AML issued in another Member State which was revoked or suspended in any other Member State.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* Signature PAYMENT METHOD SUBMISSION INSTRUCTIONS Complete Payment Form LICACC 01 Please refer to Department s official webpage for application form and details of fees required* Once your application is completed your application should be posted along with the required documentation to Please note that failure to submit all required documentation will result in the return of your application* I have submitted all required documentation please tick a Certified true copies of worksheets or logbooks b Copy of passport or other National Identity document c Original DCA National Validation.

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