Victory Aviation Club Annual Currency Questionnaire



2020 Victory Aviation Club Annual Currency Questionnaire

COMPLETION OF THIS FORM IS REQUIRED, REGARDLESS OF WHETHER OR NOT YOU HAVE FLOWN IN THE PAST YEAR.

DO NOT return this form by E-mail! DO-NOT RETURN THIS FORM TO THE TREASURER WITH YOUR BILL PAYMENT!!! PRINT AND RETURN HARD COPY BY SNAIL-MAIL IN A SEPERATE ENVELOPE TO:

Jan Jansen Please return form intact; do NOT cut

9504 Haddington Ct. out address for use as a mailing label.

Cincinnati, Ohio 45251

Please provide all information requested and sign at the bottom. This questionnaire MUST be completed by all members, signed, and returned to the address shown above no later than 15 November in order to maintain your flying privileges, as specified in the Club Operating Rules.

By direction of the club officers and trustees, flying privileges will be immediately suspended for anyone whose questionnaire has not been returned by the above deadline. NO EXCEPTIONS!

FILL OUT ON COMPUTER, THEN PRINT AND MAIL.

Set printer to print entire form on a single page.

Please read and answer every question carefully. If N/A, mark it so.

Name       A/C & Phone No.       Email (in case of questions)      

(FILL IN; don’t just check the box.)

1. Do you have a valid medical certificate or a valid BasicMed certification or are you a pre-solo student?

Yes No Check this box if pre-solo student.

2. Have you satisfied the FAA Biennial Flight Review (BFR) requirements?

Yes No N/A (student)

3. Have you received at least one hour of flight instruction during the past 12 months in the highest-HP aircraft you are currently authorized to fly as required by the Club Operating Rules, paragraph 3.2.3.g?

Yes No

4. Have you, within the past 12 months, had an aircraft accident, incident, or unreported claim?

Yes No Attach explanation (required).

5. Have you, within the past 12 months, had your pilot’s or driver’s license surrendered, suspended, or revoked; or have you been arrested for or charged with operating an aircraft or motor vehicle while under the influence of drugs or alcohol?

Yes No Attach explanation (required).

6. (Required) I hereby certify that I have read and understand the Victory Aviation Club Operating Rules.

Notes: If you answered No to questions 1, 2, or 3, these requirements must be met to fly club aircraft.

If you answered Yes to either question 4 or 5, you are required to attach a full explanation. (AVEMCO requires explanatory information for “Yes” answers to question 4 or 5.) Providing any false information constitutes grounds for immediate dismissal from the club.

EMERGENCY CONTACT INFO: Please provide contact info, even if unchanged from last year. If last year’s contact info is no longer valid, note it accordingly.

Emergency Contact (one name only; no address)      

(Name AND Relationship—MARK “N/A” IF YOU WANT NO CONTACT LISTED)

Primary Phone (A/C & No.)       Secondary Phone (A/C & No.)      

Signature ____________________________________________ Date __________________________

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download