Licensing service

Rue du Progrès 56
1210 Brussels
Tel. : 02/277 43 11
part66@mobilit.fgov.be Box for Licensing Service only

APPLICATION FOR INITIAL/AMENDMENT/RENEWAL

OF PART 66 AIRCRAFT MAINTENANCE LICENCE
(PART-66 AML)

Name: First Name:

I wish to apply for (tick relevant box):

An INITIAL Part-66 licence

An AMENDMENT to my Part-66 licence
A RENEWAL of my Part-66 licence

Addition of a new (sub)category(ies)

Rating A B1 B2 B3 C

Aeroplane - turbine
Aeroplane - piston
Helicopter - turbine
Helicopter - piston
Avionics
Piston engine non-pressurised aeroplanes MTOM of ≤2000kg
Large aircraft
Aircraft other than large aircraft
I enclose:
A certificate for credits (if relevant)
A copy of certificates for my training and/or Part-66 basic knowledge exams
A detailed description of my experience in aircraft maintenance
Addition of new rating(s) for type of aircraft or aircraft group(s)
Type of aircraft (with motor type) or group B1 B2 B3 C

I enclose:

A copy of my certificates for my theory training classes in aircraft type and/or type examinations
A copy of certificates for my practical classes in aircraft type and/or my experience

A description of my experience in aircraft type maintenance (OJT) (where relevant)

DOC/L-PEL/0200-51, issue3, 1/08/2012 EASA FORM 19

www.mobilit.belgium.be
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 Limitation removal
Limitation Certificate reference number

I enclose:
A copy of the certificates for corresponding conversion exams
A description of my experience with the limitation (where relevant)

Enclose national privileges beyond the application of Part-66

Aircraft or groups of aircraft that are not a part of Annex 1

National privileges

I enclose:
Proof of national certification privileges (where relevant)

DOC/L-PEL/0200-51, issue3, 1/08/2012 EASA FORM 19

www.mobilit.belgium.be
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 Application for conversion of my certifying staff qualification valid in Belgium to a PART 66 licence

I currently hold the following certi-

fication staff rating:
Within the following organisation

I enclose:
A copy of my accreditation issued by the approved maintenance body

I wish for my aircraft type ratings connected to my certifying staff qualification

to be written on my Part-66 licence:

Type of aircraft (with motor type) or group B1 B2 C

I enclose
A copy of my accreditation (example: company licence) issued by the approved
maintenance body

A copy of certificates for my training classes in aircraft type and/or my experience

Please note: to be completed only for conversion of national certification privileges prior to the date of entry into force of
the Part-66 regulations and for aircraft types for which you hold certification privileges

DOC/L-PEL/0200-51, issue3, 1/08/2012 EASA FORM 19

www.mobilit.belgium.be
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 Applicant's personal details:
Name:
First Name:
National register number
Place of Birth :
Date of Birth :
Nationality :
Adress
Street:
Number:
Zip Code:

Town:
Country:
Phone Number / Mobile:
E-mail:

I enclose :
A copy of my identity card or passport.

Details of the employer:

Name
Reference of the approved
maintenance body:

Adress

Street:
Number:

Town:

Zip Code:

Country:

Phone Number:

Email:

Part-66 Aircraft Maintenance Licence Details:

Licence number:

Delivery date:

Language of the Part - 66 Licence:

French [+ English]
Dutch [+ English]

DOC/L-PEL/0200-51, issue3, 1/08/2012 EASA FORM 19

www.mobilit.belgium.be
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 I declare by the present that:
1. I am not holding any Part-66 Aircraft maintenance licence issued in another Member State,
2. I have not applied for any Part-66 Aircraft maintenance licence in another Member State, and
3. I never had a Part-66 issued in another Member State which was
revoked or suspended by any other Member State.

I also understand that any incorrect information could disqualify me from holding a Part-66 Aircraft
maintenance licence.
I enclose:
My current Part-66 licence (if relevant)
A copy of proof of payment

Name:

Signature: Date:

Received on

The fee amount is:

For issuing EUR 63 (valid for 2014)
for a modification EUR 31 (valid for 2014)
for a renewal EUR 31 (valid for 2014)
The amount should be paid, before the service is carried out, to the following account:

IBAN BE51 6792 0060 2262

BIC PCHQ BEBB

DOC/L-PEL/0200-51, issue3, 1/08/2012 EASA FORM 19

www.mobilit.belgium.be
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