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Pilot History
Name:
Address:
City:
State:
Select One
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip:
Phone:
Email:
Date of Birth:
Certificate(s) held:
ATP
COMM
IFR
CFI
(Check all that apply)
Aircraft ratings held:
Total logged hours – all aircraft:
Total logged hours – retractable:
Total logged hours – multi-engine:
Total logged hours – turbo prop:
Instruction given:
Total make and model hours – (in applicable aircraft flown)
Aircraft
Number of hours
1.
2.
3.
4.
5.
6.
7.
8.
9.
Any losses, waivers or violations?
Yes
No
If yes, please explain:
Have you attended Flight Safety/Simuflight?
Yes
No
If yes, when and what aircraft:
Do you attend Flight Safety or Simuflight recurrent training?
Annually
Biannually
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