AvPac Fleet Pilot History Form

Complete form in entirety by checking all boxes that apply and filling in all blanks. Then sign and date at the bottom of the form. Electronic Signature Accepted

GENERAL INFORMATION

Pilot's Name*:

Named Insured:

Street Address:

City, State, Zip:

Mobile Phone*:

Alt. Phone:

DOB:

Skype:

Email address:

CURRENT LICENSE / RATINGS (Place "X")

Pilot:
Owner PilotPrivate PilotCommercial PilotAirline Transport PilotMEIFull-Time Pro-PilotInstrumentMulti-Engine LandCFICFII

FAA Certificate Numbe:

Date & Class - Last Medical:

LOGGED FLIGHT HOURS (TOTALS) AIRCRAFT MAKE/MODEL TO BE FLOWN

Total Logged Hours:

Pilot In Command:

Turbo-Prop SIC:

Turbo-Prop PIC:

Turbo-Jet SIC:

Turbo-Jet PIC:

Total Turbine Aircraft Hours:

Multi-Engine:

Retractable Gear:

Tailwhee:

Hours Last 12 Months All A/C:

Part 135 Hours:

A/C #1 Make and Model:

Simulator Training School Name:

Last Sim. Training Event (Date):

A/C #2 Make and Model:

Simulator Training School Name:

Last Sim. Training Event (Date):

A/C #3 Make and Model:

Simulator Training School Name:

Last Sim. Training Event (Date):

A/C #4 Make and Model:

Simulator Training School Name:

Last Sim. Training Event (Date):

Total PIC Hours Logged:

Total SIC Hours Logged:

Hours Last 12 Months:

Total PIC Hours Logged:

Total SIC Hours Logged:

Hours Last 12 Months:

Total PIC Hours Logged:

Total SIC Hours Logged:

Hours Last 12 Months:

Total PIC Hours Logged:

Total SIC Hours Logged:

Hours Last 12 Months:

QUESTIONS: (Type YES or NO and give explanation for YES answers)

Have you ever had an aircraft Accident, Incident or Violation? (If YES, give explanation)

Has your driver's license every been suspended or revoked? (If YES, give explanation)

Have you ever been convicted of driving a motor vehicle under the influence of alcohol or narcotics? (If YES, give explanation)

Have you ever been penalized for a FAR violation? (If YES, give explanation)

Have you ever been convicted of, or are you under indictment in a legal action involving drugs or narcotics? (If YES, give explanation)

Are you flying under a waiver? (If YES, give explanation)

Has any insurance company and/or Underwriter ever cancelled, non-renewed, or declined coverage on your behalf? (If YES, give explanation)

Notes (use separate sheet if necessary): (If YES, give explanation)

By signing below I warrant the truth of my responses and that nothing material has been withheld or suppressed.

Person completing this form:

Date of Signature:

Pilot's Signature: