A. APPLICANT’S DETAILS
1. Name	2. Address 5. Phone Number 6. E-mail
3. Date and place of birth
4. Nationality
B. EMPLOYER’S DETAILS (if applicable)
1. Name	2. Address
3. Maintenance Organisation Approval Reference	4. Tel	5. E-mail
C. DETAIL OF PART-66 AML HELD
1. Issuing Authority	2. Licence N°
3. Date of issue	4. Expiry date
(Sub)categories	A	B1	B2	B2L	B3	C	L (see below)
Aeroplane Turbine
Aeroplane Piston
Helicopter Turbine
Helicopter Piston
Avionics	See system ratings below
Piston engine non-pressurised aeroplanes of MTOM of 2T and below
Complex motor-powered aircraft
Aircraft other than complex motor-powered aircraft
System ratings for B2L licence:
1. Autoflight
2. Instruments
3. Com/nav
4. Surveillance
5. Airframe systems
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
L4G: ELA2 gas airships
L5: Gas airship other than ELA2
Limitation removal (if applicable): …………………………………………………………………………………………………………………………………………………………. …………………………………………………………………………………………………………………………………………………………. …………………………………………………………………………………………………………………………………………………………. …………………………………………………………………………………………………………………………………………………………. …………………………………………………………………………………………………………………………………………………………. …………………………………………………………………………………………………………………………………………………………. ………………………………………………………………………………………………………………………………………………………….
D. TYPE ENDORSMENTS/RATING ENDORSMENT (if applicable)
Type/rating endorsement as per Appendix I to AMC to Part-66	Category	Limitations
E. ADDDITIONAL INFORMATION
F. APPLICATION AND DECLARATION
I confirm that the information provided on this form is complete and correct. I wish to apply for Luxembourg to become the state of licence issue for my Part-66 AML licence. I accept that the Civil Aviation Authority of Luxembourg will apply to the current Authority (state of issue) for verification of personal and licensing details in accordance with Part-66 regulation. I understand the conditions necessary to exercise the privileges of the licence. I herewith confirm that: 1. I am not holding any Part-66 AML Licence issued by any further Member State, 2. I have not applied for a Part-66 AML Licence in another Member State and 3. I never had a Part-66 AML Licence issued by another Member State which was revoked or suspended in any other Member State.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 Licence.
G. SITUATION
My application for the transfer of an EU Member State PART-66 AML Licence to Luxembourg is made exclusively for administrative convenience due to the following reason(s): (please tick)
Luxembourgish citizen
Permanent resident of Luxembourg
Employed by a Luxembourgish company
Employer:
Home base of company:
Other (please specify):
Signed:	Name:	Date:
H. SUBMISSION INSTRUCTIONS AND ANNEXES
Please send your completed application form, accompanied by all applicable annexes, to: Direction de l’Aviation Civile Bureau des Licences 4, rue Lou Hemmer L-1748 Luxembourg Luxembourg
Copy of EU Member State Part-66 Aircraft maintenance licence
Copy of ID (passport or ID-Card)
Certificate of Residency
Certificates of recognitions for basic and/or type training (theoretical & practical)
Confirmation of residency stating that the applicant is living more than 185 days in a calendar year in Luxembourg, or Working contract as mechanic / confirmation by employer (if not having residency in Luxembourg), or Others (please specify):
Proof of payment of the fee: IBAN: LU77 0019 3655 1997 3000 / Bic: BCEELULL Account holder: ALSA S.A. / Address: 4, rue Lou Hemmer, L-1748 Luxembourg Reference: 26-a) / Amount: 191€

INFORMATION NOTE ON DATA PROTECTION

NOTICE D’INFORMATION SUR LA PROTECTION DES DONNEES

Personnel licences
Licences du personnel

Personal data are processed for the purpose of aviation safety by guaranteeing that only persons possessing the required competences obtain a pilot licence, aircraft maintenance licence or cabin crew attestation.	Les données à caractère personnel sont traitées en vue de la sécurité des activités aériennes en garantissant que seules les personnes possédant les compétences requises obtiennent une licence de pilote, une licence de maintenance d’aéronef ou un certificat de membre d’équipage.
The data subject has the right : to access to their personal data, to rectification or erasure of personal data or restriction of processing, to object to processing, by contacting the data protection officer (dpo@av.etat.lu). Proof of identity has to be included in the request (ex. copy of identity card or passport, licence number, etc.).	Toute personne concernée a le droit : d’accéder à ses données personnelles, de demander la rectification ou l’effacement des données personnelles, ou la limitation du traitement, de s’opposer au traitement, en contactant le délégué à la protection des données (dpo@av.etat.lu). Une preuve de 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 the issuance, renewal/revalidation or transfer of the licence or attestation.	Le fait de ne pas fournir les données à caractère personnel requises à la DAC fera obstacle à la délivrance, le renouvellement/la revalidation ou le transfert de la licence ou du certificat en question.
For more detailed information on the protection of your personal data, please consult our website: https://dac.gouvernement.lu/en/data-protection.html	Pour des informations plus détaillées sur la protection de vos données personnelles, veuillez consulter notre site web : https://dac.gouvernement.lu/fr/protection-donnees.html