EMPLOYEE/CONTRACTOR PERSONAL INFORMATION FORM

Identity document and Click or tap here to enter text.

its number*
Declaration home Click or tap here to enter text.
address*

Contact phone(s) and Click or tap here to enter text.

e-mail*

Date of birth and place* Click or tap here to enter text.

Citizenship* Click or tap here to enter text.

Documents are ☐copies of identity documents

provided* ☐documents confirming the impeccable of the reputation

Residence(s), State(s) where you have lived for the past 5 years and longer periods than 6
months when you lived abroad. Please specify in chronological order up to the present, i.e.
until the date of filling out the application. *

From To Address, city, country

Day Month Year Day Month Year
 Please list all the places of employment (or education) for the last 5 years.
Please specify in chronological order up to the present, i.e. until the date of filling out the
application. *

From To Company name, position

Day Month Year Day Month Year

During 5 years, periods longer than 28 calendar days (breaks) during which you did not
work or study anywhere (if any). Please write short story of what you have been doing
when you have not been working or studying and provide the contact details (name,
surname, phone or email address) of someone who can confirm. Please specify in
chronological order up to the present, i.e. until the date of filling out the application. *
From To Short story, name, surname, phone persons
Day Month Year Day Month Year who can to confirm

* - Information is very important and must be to filled.

 Education, institution name, subject of study, degree if applicable please limit only to
major education, aviation-related and aviation security courses, if applicable.

Years Educational institution, country

From To

FLYING EXPERIENCE

Aircraft Total hours

class/type

PERSONAL INFO
Marital status,
number of children
Languages spoken
Driver’s license YES/NO
Next of kin to be contacted
Name, relation to you, contact
phone(s)

I confirm that:

1) I have not been convicted of a careless, minor or aggravated crime and I do not have an
outstanding or expunged criminal record.
2) I have not been convicted of a serious or very serious crime and/or for terrorist and/or
terrorist-related crimes.
3) I have not been convicted of a criminal offense and do not have an outstanding sentence
(except in cases where a person is exempted from serving a sentence).
4) in the last 2 years prior to the submission of the application, I have not received two or more
administrative penalties for violations of aviation security requirements.
5) I have no interest hostile to the Republic of Lithuania, I do not cooperate and have not
cooperated, I have not maintained and do not maintain relations with the military, intelligence
or security service of a foreign state or with a person who cooperates or maintains relations
with the military, intelligence or security service of a foreign state.
6) I have not participated in, or participate in, a terrorist organization or terrorist group, nor
have I been in contact with a person belonging to a terrorist organization or group.
7) in the last 5 years, I have not participated in and participate in the activities of an unregistered
movement in which participation would give reason to believe that I, who require a thorough
examination of a person's reputation, is unsuitable for the performance of a particular function.
8) that the information presented in this “Employee/Contractor personal information” form is
true, and I understand my full responsibility for records on this form.

I agree and had been informed that the Company would carry out a check of my criminal
charges and convictions of all available law enforcement systems, including any local police
records, also would check the accuracy and reliability of my provided information (personal
and professional) completed in the Employee/Contractor Personal Information Form from the
previous employers, educational institutions, public authorities and other persons specified by
me in order to comply with the legal requirements established by Commission Regulation (EU)
2015/1998.

Place: Date:

Signature: Name, Surname (in block letters):

The storage period of the Consent (and the related Data) is 1 (one) year after the end of the period of the
employment or contractual relations.