PILOT APPLICATION (COMPLETE ENTIRE FORM)



PILOT APPLICATION (COMPLETE ENTIRE FORM)PILOT HISTORYPILOT NAME: FORMTEXT ?????DAYTIME PHONE: # FORMTEXT ?????ADDRESS: FORMTEXT ?????ADDRESS: FORMTEXT ?????DATE OF BIRTH: FORMTEXT ?????DRIVER’S LICENSE #/STATE: FORMTEXT ?????AIRMAN’S CERT.: # FORMTEXT ?????MED. CLASS & EXP. DATE: FORMTEXT ?????ARE YOU A STATE EMPLOYEE? FORMCHECKBOX YesAGENCY: FORMTEXT ?????HOW OFTEN DO YOU FLY ON STATE BUSINESS? ANNUAL FLIGHTS: FORMTEXT ????? ANNUAL HOURS: FORMTEXT ?????PURPOSE OF FLYING ON STATE BUSINESS? FORMTEXT ?????OCCUPATION: FORMTEXT ?????If the answer to any of the following questions is yes, please give detail on separate sheet.YESNOHave you ever had any aircraft accidents? FORMCHECKBOX FORMCHECKBOX Have you ever been cited for violations of civil/military aviation regulations? FORMCHECKBOX FORMCHECKBOX Are you flying subject to limitations or a waiver? FORMCHECKBOX FORMCHECKBOX Has your driver’s license ever been suspended or revoked? FORMCHECKBOX FORMCHECKBOX Have you been arrested for operating a vehicle while under the influence of alcohol or drugs? FORMCHECKBOX FORMCHECKBOX Have you had any automobile accidents within the last five years? FORMCHECKBOX FORMCHECKBOX CERTIFICATES / RATINGSIndicate all certificates you currently hold: FORMCHECKBOX ?Student FORMCHECKBOX ?Private FORMCHECKBOX ?Commercial FORMCHECKBOX ?Airline (ATR) FORMCHECKBOX ?Instructor FORMCHECKBOX ?Instrument Rating FORMCHECKBOX ?Single Engine Land FORMCHECKBOX ?Multi Engine Land FORMCHECKBOX ?HelicopterList all aircraft type ratings you currently hold: FORMTEXT ?????List all Manufacturer’s Ground and Flight Schools and dates you have attended for each aircraft make and model: FORMTEXT ?????Indicate date of your last biennial flight review and list if it was VFR or IFR: FORMTEXT ?????FLYING EXPERIENCE IN LOGGED HOURSPILOT-IN-COMMAND ONLYSPECIIFY ALL MAKE AND MODELSLAST 12 MONTHSLAST 90 DAYSTOTAL LOGGED HOURSALL SINGLE FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????ENGINE FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????FIXED WING/GEAR FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????OR FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????RETRACTABLE FORMTEXT ?????GEAR FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????MULTI ENGINE FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????PISTON FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????MULTI ENGINE FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????TURBINE FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????HELICOPTERPISTON: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????HELICOPTERTURBINE: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????AIRCRAFT INFORMATIONTYPES OF AIRCRAFT YOU OPERATEYEARMAKEMODELFAA#STATE OWNED AIRCRAFT: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????OWNED, BORROWED OR RENTED AIRCRAFT: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Borrowed or owned private aircraft (attach certificate of insurance providing evidence of $1,000,000 minimum Aircraft liability including passengers)I CERTIFY THAT THE STATEMENTS I HAVE MADE IN THE PILOT APPLICATION TO BE THE BEST OF MY KNOWLEDGE AND BELIEF.PILOT SIGNATURE:DATE: FORMTEXT ?????APPROVED BY:DATE:FOR: FORMCHECKBOX -SEFG FORMCHECKBOX -SERG FORMCHECKBOX -MEU FORMCHECKBOX -HELI ................
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