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Pilot Experience Form Summary

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PILOT'S NAME:

MAILING ADDRESS:

*Table layout with no shading or background color

EMAIL:

PHONE:

CELL:

Age:

Driver's License State:

Driver's License Number:

Layout:

Present Employer:

Date Employed:

Full Time/Part Time?:

Job Title:

Percentage of Time Spent on Non-Flying Duties:

Education: Highest Level Completed:

FAA Airman Certificate Number:

Date of Last FAA Flight Physical:

Class of Medical Certificate Held:

Waivers, Limitations or Conditions on Medical Certificate:

Physical Impairments:

Date of Last FAA Biennial Flight Review (BFR)::

Type of Aircraft Used for Proficiency Check:

Date of Last FAA Instrument Proficiency Check (IPC):

Pilot Certificate/Ratings:

Aircraft Ratings:

Please List Other Ratings Here:

Aircraft (Type Ratings):

Mechanic Ratings:

Total Hours:

Pilot in Command:

Multi-Engine:

Turbo Prop:

Turbo Jet:

Hours Last 12 Months in All Aircraft:

SINGLE ENGINE FIXED GEAR::

SINGLE ENGINE RETRACTABLE GEAR::

MULTI-ENGINE UNDER 12,500 LBS::

MULTI-ENGINE OVER 12,500 LBS::

SINGLE PILOT HOURS LOGGED IN AIRCRAFT REQUIRING A TYPE RATING::

FIXED WING TURBO PROP::

FIXED WING TURBO JET::

INSTRUMENT FLYING::

AERIAL APPLICATION::

CONVENTIAL GEAR (TAILWHEEL)::

HELICOPTER - RECIPROCATING POWERED::

HELICOPTER - TURBINE POWERED::

INSTRUMENT FLYING, LAST 12 MONTHS::

MILITARY HOURS LOGGED::

ARE PILOT HOURS DOCUMENTED IN PILOT LOG BOOK?:

AIRCRAFT 1, MAKE & MODEL::

AIRCRAFT 2, MAKE & MODEL::

AIRCRAFT 3, MAKE & MODEL::

AIRCRAFT 4, MAKE & MODEL::

TOTAL HOURS FOR AIRCRAFT 1::

TOTAL HOURS FOR AIRCRAFT 2::

TOTAL HOURS FOR AIRCRAFT 3::

TOTAL HOURS FOR AIRCRAFT 4::

HOURS LAST 12 MONTHS FOR AIRCRAFT 1::

HOURS LAST 12 MONTHS FOR AIRCRAFT 2::

HOURS LAST 12 MONTHS FOR AIRCRAFT 3::

HOURS LAST 12 MONTHS FOR AIRCRAFT 4::

Make & Model:

School:

Course:

Date Completed:

Make & Model:

School:

Course:

Date Completed:

Make & Model:

School:

Course:

Date Completed:

Make & Model:

School:

Course:

Date Completed:

As pilot-in-command or co-pilot have you ever had an aircraft claim, incident or accident, or been cited or fined for violation of any aviation regulation of any country?:

Has any FAA, Transport Canada, or military pilot certificate ever been suspended or revoked?:

Have you ever been convicted of a felony or are you under indictment for a felony?:

Have you ever been arrested, convicted of or pleaded guilty to a charge of reckless driving or driving a motor vehicle under the influence of alcohol or narcotics?:

Has your driver’s license ever been suspended or revoked?:

Have you ever been convicted of or are you under indictment in a legal action involving drugs or narcotics?:

Has any insurance company or underwriter cancelled, declined, or refused to renew any insurance on your behalf?:

Other Comments (describing any of the answers above, as needed)::

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Your legal name

Your email address

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Timestamp

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May 22, 2023 3:38 pm EDT

Pilot Experience Form Summary Uploaded by Wes Wikel - wes@518digital.com IP 67.222.246.253