Pilot Record Application
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Business/Company Name
Pilot
Last Name
First Name
Address
Street
City
State
Alabama
Alaska
Alberta
Arizona
Arkansas
British Columbia
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Manitoba
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Brunswick
New Hampshire
New Jersey
New Mexico
New York
Newfoundland and Labrador
North Carolina
North Dakota
Northern Mariana Islands
Northwest Territories
Nova Scotia
Nunavut
Ohio
Oklahoma
Ontario
Oregon
Pennsylvania
Prince Edward Island
Puerto Rico
Quebec
Rhode Island
Saskatchewan
South Carolina
South Dakota
Tennessee
Texas
United States Virgin Islands
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Yukon
Zip Code
Phone Number
E-mail Address
Date of Birth
Name of Insured
Last Medical
Date
Class
FAA Certificate No
Date First Certified as Pilot
Date of last FAA
Physical Examination
Physical Imparments, If any
Waivers, Limitaions or Conditions
specified on medical certificates, if any
Employment History
Present Employer
Date Employed
Address
Street
City
State
Alabama
Alaska
Alberta
Arizona
Arkansas
British Columbia
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Manitoba
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Brunswick
New Hampshire
New Jersey
New Mexico
New York
Newfoundland and Labrador
North Carolina
North Dakota
Northern Mariana Islands
Northwest Territories
Nova Scotia
Nunavut
Ohio
Oklahoma
Ontario
Oregon
Pennsylvania
Prince Edward Island
Puerto Rico
Quebec
Rhode Island
Saskatchewan
South Carolina
South Dakota
Tennessee
Texas
United States Virgin Islands
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Yukon
Zip Code
Position(s) Held
Is Piloting Airecraft Your Promary Profession?
Yes
No
If no, Describe
Are you a Full-Time Employeee for this operation or Contract Pilot?
Full-Time Employee
Contract
If you are a contract pilot, who esle do you fly for?
What percentage of your piloting time is spent flying for other operations?
0 Items
Previous Employer
Position
From
To
Education
Highest Years Completed
High School
1
2
3
4
College
1
2
3
4
Graduate School
1
2
3
4
0 Items
Level of Education
Name of School
Attended
From
Attended
To
Graduated
Current Certifications & Ratings
License (check all that apply)
ATP
Instrument: Class
Private
Student
Commercial
Multi-Engine: Land
Rototcraft
Glider
Multi-Engine: Sea
Single Engine: Land
Instructor: Class
Night
Single Engine: Sea
Other
Type Rating
(Specify Each Aircraft)
Last Biennial
Flight Review
Date
Make & Model
Last Instrument
Proficiency Exam
Date
Make & Model
Flight and Ground School Training Courses
Specific to Make & Model Aircraft which you are applying to fly
Type of Aircraft
Frequency
Name of Facility
Last Successful
Completion Date
1.
Type of Aircraft
Frequency
Name of Facility
Last Successful Completion Date
Training Type
Initial Type Training
Recurrent Training
Full-axis Motion Simulator Training
In Aircraft Training
Ground School Only
2.
Type of Aircraft
Frequency
Name of Facility
Last Successful Completion Date
Training Type
Initial Type Training
Recurrent Training
Full-axis Motion Simulator Training
In Aircraft Training
Ground School Only
3.
Type of Aircraft
Frequency
Name of Facility
Last Successful Completion Date
Training Type
Initial Type Training
Recurrent Training
Full-axis Motion Simulator Training
In Aircraft Training
Ground School Only
4.
Type of Aircraft
Frequency
Name of Facility
Last Successful Completion Date
Training Type
Initial Type Training
Recurrent Training
Full-axis Motion Simulator Training
In Aircraft Training
Ground School Only
5.
Type of Aircraft
Frequency
Name of Facility
Last Successful Completion Date
Training Type
Initial Type Training
Recurrent Training
Full-axis Motion Simulator Training
In Aircraft Training
Ground School Only
Logged Pilot Hours
Total Pilot In-Command Hours for All Aircraft
Itemization of Hours
Class
Make/Model to be flown
Total
Time
PIC Hours
SIC Hours
Last 90 Days
Last 12 Months
1
Make & Model
Total Time
PIC Hours
SIC Hours
Last 90 Days
Last 12 Months
2
Make & Model
Total Time
PIC Hours
SIC Hours
Last 90 Days
Last 12 Months
3
Make & Model
Total Time
PIC Hours
SIC Hours
Last 90 Days
Last 12 Months
4
Make & Model
Total Time
PIC Hours
SIC Hours
Last 90 Days
Last 12 Months
Single Engine
Fixed
Total Time
PIC Hours
SIC Hours
Last 90 Days
Last 12 Months
Single Engine
Retractable
Total Time
PIC Hours
SIC Hours
Last 90 Days
Last 12 Months
Multiengine
Total Time
PIC Hours
SIC Hours
Last 90 Days
Last 12 Months
Turbine
Total Time
PIC Hours
SIC Hours
Last 90 Days
Last 12 Months
Piston Rotorwing
Total Time
PIC Hours
SIC Hours
Last 90 Days
Last 12 Months
Turbine Rotorwing
Total Time
PIC Hours
SIC Hours
Last 90 Days
Last 12 Months
Total Hours
All Airecraft
Total Time
PIC Hours
SIC Hours
Last 90 Days
Last 12 Months
Additional Information
I certify that the statements in this form are true and that no material information has been withheld or suppressed.
Have you ever had an aircraft claim or accident?
Yes
No
Have you ever been cited or fined for violation of an aviation regulation?
Yes
No
Has your pilot certificate ever been suspended or revoked?
Yes
No
Have you ever been convicted of a felony or are you under indictment for a felony?
Yes
No
Have you ever been convicted of driving a motor vehicle under the influence of alcohol or narcotics, or convicted of reckless driving?
Yes
No
Has your driver's license even been suspended or revoked?
Yes
No
Have you ever been convicted of or are you under indictment in a legal action involving drugs or narcotics?
Yes
No
Have you ever experienced or been treated for a chemical dependency?
Yes
No
Are you regularly using any medication?
Yes
No
Have you ever been discharged or asked to resign?
Yes
No
If yes to any above, please explain
Signature
I certify that the statements in this form are true and that no material information has been withheld or suppressed.
Name
Date
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