EASA Form 19 Issue 5 NOV2020
EASA Form 19 Issue 5 NOV2020
EASA Form 19 Issue 5 NOV2020
A. APPLICANT’S DETAILS
1. Name 2. Address
3. Nationality
5. Phone Number
4. Date and place of birth
6. E-mail Address
B. PART-66 AML DETAILS (if applicable)
1. Licence N° 1. Date of issue
D. APPLICATION
APPLICATION FOR: (Tick relevant boxes)
Initial AML Amendment of AML Renewal of AML
L- Licence subcategories:
L1C: Composite sailplanes
L1: Sailplanes
L2C: Composite powered sailplanes and composite ELA1 aeroplanes
L2: Powered sailplanes and ELA1 aeroplanes
L3H: Hot-air balloons
L3G: Gas balloons
L4H: Hot-air airships
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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:
I also understand that any incorrect information could disqualify me from holding a PART-66 AML.
F. CREDITS
I wish to claim the following credits (if applicable):
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Position: Date:
Payment of the following taxes must be made to BCEE IBAN LU77 0019 3655 1997 3000, Bic: BCEELULL, Bénéficiaire:
ALSA S.A.
Address: 4, rue Lou Hemmer, L-1748 Luxembourg
Personnel licences
Licences du personnel
Personal data are processed for the purpose of Les données à caractère personnel sont traitées
aviation safety by guaranteeing that only persons en vue de la sécurité des activités aériennes en
possessing the required competences obtain a garantissant que seules les personnes possédant
pilot licence, aircraft maintenance licence or les compétences requises obtiennent une licence
cabin crew attestation. de pilote, une licence de maintenance d’aéronef
ou un certificat de membre d’équipage.
The data subject has the right : Toute personne concernée a le droit :
- to access to their personal data, - d’accéder à ses données personnelles,
- to rectification or erasure of personal - de demander la rectification ou
data or restriction of processing, l’effacement des données personnelles,
- to object to processing, ou la limitation du traitement,
by contacting the data protection officer - de s’opposer au traitement,
([email protected]). Proof of identity has to be en contactant le délégué à la protection des
included in the request (ex. copy of identity card données ([email protected]). Une preuve de
or passport, licence number, etc.). l’identité doit être jointe à la demande (ex. copie
de la carte d’identité ou du passeport, numéro de
la licence, etc.).
Failure to provide the requested data will prevent Le fait de ne pas fournir les données à caractère
the issuance, renewal/revalidation or transfer of personnel requises à la DAC fera obstacle à la
the licence or attestation. délivrance, le renouvellement/la revalidation ou
le transfert de la licence ou du certificat en
question.
For more detailed information on the protection Pour des informations plus détaillées sur la
of your personal data, please consult our protection de vos données personnelles, veuillez
website: consulter notre site web :
https://dac.gouvernement.lu/en/data- https://dac.gouvernement.lu/fr/protection-
protection.html donnees.html