Pilot History Form Home » Pilot History Form Pilot History Form Please fill out the form below Please enable JavaScript in your browser to complete this form.Pilot Name *FirstLastEmail *AddressAddress 1Address 2City State/ProvinceZip/Postal CodeCountryWork PhoneCell PhoneFaxCertificate NumberOccupationEmployerPilot Certificates Now HeldStudentPrivateCommercialATPFlight InstructorRecreational FAA Medical Certificate (Date Issued)MM/DD/YYYYClassWaivers (If none, write none)FAA Pilot Ratings Now HeldASELAMELIFRHelicopterSESMESGliderOtherTraining and Refresher Training Describe Simulator Flight TrainingAircraft TypeSchool DateMedical ClassLast Medical DateMM/DD/YYYYDo you hold a current FSI Pro Card or Simuflite Card?YesNoDate of last Biennial Flight Review or equivalentMM/DD/YYYYDo you participate in FAA Pilot Proficiency Award Program?YesNoTotal HoursMulti-Engine HoursTurbo-Prop HoursTail-Wheel HoursGlider HoursAmphibious HoursRetractable Gear HoursHelicopter HoursJet HoursSeaplane HoursInstructor HoursOther HoursOther Hours Make and ModelLast 90 Days HoursLast 12 Months Hours Please Explain fully and YES answers to the following questions below:As pilot in command or co-pilot have you had or been involved in any aircraft accidents or incidents?As pilot in command or co-pilot have you been found guilty of or been penalized, disciplined, fined or violated for any civil or military Air Regulations? Has your automobile drivers license ever been suspended or revoked?Have you ever been arrested for operating an automobile under the influence of alcohol or drugs?Have you had any automobile accidents within the last five years?Any aircraft / aviation insurance claims or losses?Have you ever been convicted or pleaded guilty to a felony?Has any insurer cancelled or declined to renew any aircraft insurance for you in the past five years?Submit
