MINISTRY OF TRANSPORTATIONS

DIRECTORATE GENERAL OF CIVIL AVIATIONS

AVIATION MEDICAL CENTER
Kota Baru Bandar Kemayoran Blok B 11 Kav. No. 4 Jakarta - Indonesia 10610
Phone : 62-21 6586 7830 Facsimile : 62-21 6585 7832
APPLICATION FOR AVIATION MEDICAL ASSESSMENT
Complete this page fully using a black ballpoint and in block letter
CONFIDENTIAL

1. Name: (First, Middle, Last) 2. ID No/Passport No.: 3. Sex

ANDRI YUDIANTO 3175102802810006 [ ] Male
[ ] Female
4. Date of birth: (DD-MM-YYYY) 5. Place and country of birth: 6. Nationality: 7. Application:
28-02-1981 MALANG, INDONESIA INDONESIA [ ] Initial
[ ] Renewal
[ ] Other ...
8. Country of licence issue: 9. Class of Medical Assessment applied for: 10. Type of licence applied for (if initial
INDONESIA [ ] 1st; [ ] 2nd; [ ] 3rd; application):
FOO
11. Occupation (principal): 12. Employer (principal): 13. Last medical examination 14. Aviation licence(s) held (type):
FLIGHT OPERATION OFFICER TRAVIRA AIRLINE Date: 23-04-2019 Licence number(s): 2061
Place: DR. NURUL WAHDAH, Country(ies) of issue: INDONESIA
SP.KP, BALAI HATPEN,
JAKARTA
15. Permanent address: 16. Company address:
PERUM SETU INDAH IVD NO 44, RT RW 02 03 SETU HANGAR PT TRAVIRA AIR JALAN TIMUR LAUT SKATEK 021
CIPAYUNG JAKARTA TIMUR HALIM PERDANA KUSUMA JAKARTA

Postcode:13880 Country:INDONESIA Postcode: Country:INDONESIA

Telephone No.: Mobile/Cell No.: 08157731771 Telephone No.:021-80870550
E-mail:andry2ti@gmail.com
17. Family physician’s name and address: 18. Any limitations on Licence/Medical Assessment?
[ ] No [ ] Yes
Details:

E-mail: Telephone No.:

19. Have you ever had an aviation Medical Assessment denied, suspended or revoked by any 20. Total flight time 21. Flight time (hours) since last
licensing authority? If yes, discuss with medical examiner. (hours): medical:
[ ] No [ ] Yes Date: Place: 0 0
Details: 22. Aircraft currently flown (e.g. Boeing 737, Cessna C150 ):
ATR 42/72-600

23. Any aircraft accident or reported incident since last medical? 24. Type of flying intended (1) e.g. commercial air transport,
flying instruction, private:
[ ] No [ ] Yes Date: Place:

Details: 25. Type of flying intended (2):

[ ] Single-crew [ ] Multi-crew

26. Do you drink alcoholic beverages? 27. Do you currently use any medication, including non-prescribed medication?
[ ] No [ ] Yes [ ] No [ ] Yes
If YES, state average weekly intake in units: If YES, state name of medication, date commenced, daily or weekly dose,
and cause (diagnosis):

28. Do you smoke tobacco products?

[ ] Never
[ ] Previously Date stopped:
[ ] Currently State type, amount and number of
years:

AMC Form No. 67-01 (09-2017)

 29. General and medical history: Do you have, or have you ever had, any of the following? YES or NO must be ticked after each question.
Elaborate YES answers in the remarks section and discuss them with the medical examiner
Yes No
101 Eye disorders/eye surgery
102 Spectacles and/or contact
lenses ever worn
103 Spectacle/contact lens
prescriptions/change since last
medical exam
104 Hay fever, other allergy
105 Asthma, lung disease
106 Heart or vascular disease
107 High or low blood pressure
108 Kidney stone or blood in urine
109 Diabetes, hormone disorder
110 Stomach, liver or intestinal
trouble
111 Deafness, ear disease
Yes No Yes No Yes No
112 Nose or throat disease or 123 Malaria or other tropical Family history of:
speech disorder disease
113 Head injury or concussion 124 A positive HIV test 140 Family history of : Heart
disease
114 Frequent or severe headaches 125 Sexually transmitted disease 141 Family history of : High blood
pressure
115 Dizziness or fainting spells 126 Admission to hospital 142 Family history of : High
cholesterol level
116 Unconsciousness for any 127 Any other illness or injury 143 Family history of : Epilepsy
reason
117 Neurological disorders; 128 Visit to medical practitioner 144 Family history of : Mental
stroke, epilepsy, seizure, paralysis, since last medical examination illness
etc
118 Psychological/ psychiatric 129 Refusal of life insurance 145 Family history of : Diabetes
trouble of any sort
119 Alcohol/drug/substance abuse 130 Refusal of issue or revocation 146 Family history of :
of aviation licence Tuberculosis
120 Attempted suicide 131 Medical rejection from or for 147 Family history of :
military service Allergy/asthma/eczema
121 Motion sickness requiring 132 Award of pension or 148 Family history of : Inherited
medication compensation for injury or illness disorders
122 Anaemia/Sickle cell trait/other 149 Family history of : Glaucoma
blood disorders

Females only:
150 Female only : Gynecological
disorders (including menstrual)
151 Female only : Are you
pregnant?
152. Remarks: If previously reported and unchanged, so state.

5. Riwayat Asma, kambuh terakhir 6 tahun yang lalu. Tidak ada penggunaan obat rutin. 26. 2013 App

30. Declaration: I hereby declare that I have carefully considered the statements I have made above and that to the best of my belief they are complete and correct. I further declare that I
have not withheld any relevant information or made any misleading statements. I understand that if I have made any false or misleading statement in connection with this application, or if I
do not consent to release the supporting medical information, the Authority may refuse to grant me a Medical Assessment or may withdraw any Medical Assessment granted, without
prejudice to any other legal action applicable pursuant to Aviation Act. No. 1 Year 2009.

CONSENT TO RELEASE OF MEDICAL INFORMATION: I hereby give my consent that all relevant medical information may be released and submitted to the Medical Assessor of the
Licensing Authority. Note: Medical in confidenceity will be respected at all times.

09 Maret 2020 ANDRI YUDIANTO dr.Irma Khrisnapandit, Sp.KP

Date Signature of applicant Signature of medical examiner

AMC Form No. 67-01 (09-2017)

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