PILOT
#1 INFORMATION |
Pilot #1
Full Name |
Date of
Birth |
Current
Employer |
Date of
last Biennial Flight Review |
Airman's
Certificate Number |
Have You
Attended Any Formal Ground & Flight Or Simulator Training For The
Requested Make & Model Aircraft ? YES
NO
IF Yes, Please Indicate Specifics
Of Training, Where Attended, and Date Last Completed.
|
Check
Any of the Following Certification and Ratings That Apply |
Student Private
Commercial |
Airline Transport(ATP)
Instructor(CFI) |
Instrument Instructor(CFII)
Rotorwing Instructor |
Multi Engine Instructor(MEI)
Instrument Rating |
Single Engine Land
Multi Engine Land |
Seaplane
Multi Engine Sea
Rotorwing |
Center Line Thrust
Glider |
Mechanic, Aircraft and Power Plant |
Type
Ratings & Endorsements(Specify) |
Pilot
#1 Aircraft Hours |
Total
Logged Hours
Multi Engine Hours |
Single
Engine Retract Hours
Tailwheel Hours |
Turbo
Prop Hours
Turbo Jet Hours |
Rotorwing
Hours
Seaplane/Amphibian Hours |
Total
Logged Hours In Make & Model |
Total
Logged Hours In Make & Model Last 90 Days |
Total
Logged Hours In Make & Model Last 12 Months |
Total
Logged Hours In All Aircraft Last 90 Days |
Total
Logged Hours In All Aircraft Last 12 Months |
PLEASE
EXPLAIN ANY YES ANSWERS TO THE FOLLOWING QUESTIONS IN THE SPACE
PROVIDED BELOW. |
1. Do you
have any physical condition(s), limitation(s) or impairment(s) that
require a waiver or special condition to be attached or indicated on
your Medical Certificate? YES
NO |
2. Has
your FAA or DOT or Military Pilot Certificate ever been suspended or
revoked? YES
NO |
3. Have
you ever been cited for any violations of Federal or Canadian Air
Regulations or have limitations ever been placed on your Pilot
Certificate? YES
NO |
4.
Arising out of the operation of a Motor Vehicle, have you had your
driver's license suspended or revoked during the past 5
years? YES
NO |
5. Have
you been convicted or pleaded guilty to a charge of reckless driving
or driving under the influence of alcohol or drugs during the past 5
years? YES
NO |
6. Have
you ever had an application for Aircraft Hull or Liability insurance
declined by an insurance company? (Question #6 not applicable in
states where prohibited by law
) YES
NO |
7. Have
you ever had any aircraft accidents or incidents while acting as Pilot
within the past five years? [If "Yes", give dates, places,
make and model of aircraft and details of
Accidents/Incidents]
YES
NO |
Explanations Below |
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|
PILOT #2
INFORMATION (only required if there
is to be more than one named pilot) |
Pilot #2
Full Name |
Date of
Birth |
Current
Employer |
Date of
last Biennial Flight Review |
Airman's
Certificate Number |
Check
Any of the Following Certification and Ratings That Apply |
Student
Private
Commercial |
Airline Transport(ATP)
Instructor(CFI) |
Instrument Instructor(CFII)
Rotorwing Instructor |
Multi Engine Instructor(MEI)
Instrument Rating |
Single Engine Land
Multi Engine Land |
Seaplane
Multi Engine Sea
Rotorwing |
Center Line Thrust
Glider |
Mechanic, Aircraft and Power Plant |
Type
Ratings & Endorsements(Specify) |
Pilot
#2 Aircraft Hours |
Total
Hours Multi
Engine Hours |
Single
Engine Retract Hours
Tailwheel Hours |
Total
Logged Hours In Make & Model |
Total
Logged Hours In Make & Model Last 90 Days |
Total
Logged Hours In Make & Model Last 12 Months |
Total
Logged Hours In All Aircraft Last 90 Days |
Total
Logged Hours In All Aircraft Last 12 Months |
PLEASE
EXPLAIN ANY YES ANSWERS TO THE FOLLOWING QUESTIONS IN THE SPACE
PROVIDED. |
1. Do you
have any physical condition(s), limitation(s) or impairment(s) that
require a waiver or special condition to be attached or indicated on
your Medical Certificate? YES
NO |
2. Has
your FAA or DOT or Military Pilot Certificate ever been suspended or
revoked? YES
NO |
3. Have
you ever been cited for any violations of Federal or Canadian Air
Regulations or have limitations ever been placed on your Pilot
Certificate? YES
NO |
4.
Arising out of the operation of a Motor Vehicle, have you had your
driver's license suspended or revoked during the past 5
years? YES
NO |
5. Have
you been convicted or pleaded guilty to a charge of reckless driving
or driving under the influence of alcohol or drugs during the past 5
years? YES
NO |
6. Have
you ever had an application for Aircraft Hull or Liability insurance
declined by an insurance company? (Question #6 not applicable in
states where prohibited by law
) YES
NO |
7. Have
you ever had any aircraft accidents or incidents while acting as Pilot
within the past five years? [If "Yes", give dates, places,
make and model of aircraft and details of Accidents/Incidents]
YES
NO |
Explanations Below |
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