Pilot Record Form

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GENERAL INFORMATION

Reference N# Owner

First name*

Last name*

Date of Birth*

FAA Airman #

Home Address

Country/Region*

Address*

City*

Zip / Postal code*

Email*

PILOT CERTIFICATION, RATINGS, & EXPERIENCE (LOGGED HOURS)

Medical Class*

Medical Expiration*

Multi choice*

Student Pilot

Sport Pilot

Private Pilot

Commercial Pilot

ATP

Total Fixed Wing

Total Retract

Total Multi

Total Tail Wheel

Hours Flown as PIC last 12 Months*

Ratings*

INSTRUMENT

CFII

CFI

MEI

DPE

A&P

Other

INSURED MAKE/MODEL EXPERIENCE & TRAINING HISTORY (Include the Make/Model to be insured or similar types)

a: Make and Model

a: Hours

a: Recurrent Training Date/ School Name

b: Make and Model

b: Hours

b: Recurrent Training Date/ School Name

c: Make and Model

c: Hours

c: Recurrent Training Date/ School Name

Date of Last BFR

Date of Last IPC

QUESTIONS (check “YES” or “NO”)

Are you flying under a waiver?*

Yes

No

Have you ever been penalized for an FAR violation?*

Yes

No

Have you ever had an aircraft accident, incident, and/or violation?*

Yes

No

Has any insurance company and/or underwriter ever cancelled, non-renewed, or declined coverage on your behalf?*

Yes

No

In the last 5 years, have you been convicted of or are you under indictment in a legal action involving drugs or narcotics?*

Yes

No

In the last 5 years, have you been convicted of driving a motor vehicle under the influence of alcohol or narcotics?*

Yes

No

In the last 5 years, has your driver’s license been suspended or revoked?*

Yes

No

Explain all YES answers (attach a separate sheet, if necessary):

File upload

Upload option for supporting documents (if necessary)

I certify that all statements on this application are complete and true to the best of my knowledge.

FL Licence: G205115

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