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Pilot History Form

Applicant:
Applicant Address:
City:
State:
Zip Code:
Pilot's Name:
Pilot Address:
City:
State:
Zip Code:
Occupation:
Employer:
How long?
Driver's license No.:
Airman Certificate No.:
Date & Class of last Medical:
Bi-Annual Flight Review Date:
Certificates and Ratings:
Student Single Engine Land
Private Multi Engine Land
Commercial Single Engine Sea
Instrument Helicopter
ATP Other
CFI
Aircraft Type Rating:
Mechanic Rating:
Aircraft
Power Plant
Total logged Civilian pilot hours:
Pilot in command: Co-Pilot
Total logged Military pilot hours:
Pilot in command: Co-Pilot
Initial pilot training obtained from: Where?
Complete Breakdown of Logged Pilot In Command Hours (Civiliam & Military Combined):
Single Engine Fixed Gear: Instrument Flying:
Single Engine Retractable Gear: Single Engine Sear:
Multi-Engine under 12,500 lbs.: Turbojet:
Multi-Engine over 12,500 lbs.: Helicopter Piston:
Turboprop: Last 90 Days:
Helicopter Turbine: Last 12 Months:
Cross Country: a) Actural Instr.:
Night Flying: b) Simulator:
Make & Model Aircraft for which approval is sought:  
Total logged Pilot in Command hours in this aircraft:
Date of last recurrent training in the make and model:  
Where attended:
Are you flying under a waiver?  
If Yes, explain:
Has your FAA or DOT license ever been suspended or revoked?    
If Yes, explain:
Have you ever had an Accident, Incident, or Violation?  
If Yes, explain:
Have you ever had an application for Aircraft Hull or Liability Insurance declined by an Insurance Company?
If Yes, explain:
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